THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


1905 

THE  RENEWAL  OF  LIFE. 


LECTURES, 


CHIEFLY  CLINICAL 


BY 

THOMAS   KING    CHAMBERS,    M.D., 

HONORARY    PHYSICIAN   TO    H.B.H.    THE    PRINCE   OF   WALES,   CONSULTING   PHYSICIAN    AND   LECTUEER    ON    THE   PRACTICE 
OP   MEDICINE   AT  ST.    MARY'S   HOSPITAL,  CONSULTING    PHYSICIAN   TO   THE   LOCK    HOSPITiL. 


FROM  THE  FOURTH  LONDON  EDITION. 


PHILADELPHIA: 

LINDSAY    &    BLAKISTON. 

18G6. 


HENliY   B.   AStlMEAD,    PRINTER, 
1102  and  1101  Sansom  Street. 


BioroediuJ 
Umry 

m 

100 

tzssr 


PREFACE 


FOURTH    EDITION 


In  the  first  two  editions  I  named  the  selection  of  clini- 
cal observations  laid  before  the  public  "  The  Renewal  of 
Life,"  meaning  thereby  to  intimate  what  is  more  fully 
stated  early  in  the  volume,  that  the  main  point  for  the 
physician's  consideration  in  disease  is  the  deficiency  of 
vital  action,  and  that  all  successful  medical  treatment  is  a 
renewal  of  that  vital  action.  To  my  annoyance  the  words 
were  found  strangely  "open  to  misrepresentation"  by 
several  of  the  literary  men  engaged  in  reviewing  the  work. 
Such  a  risk  seemed  to  outweigh  the  advantage  of  ex- 
pressing in  an  epigrammatic  form  the  principles  advocated, 
and  led  me  to  take  the  unusual  course  in  the  third  edition 
last  year  of  leaving  out  a  great  part  of  the  title.  I  tried 
to  justify  the  change  of  name  by  large  additions  to  the 
original  matter,  dovetailing  into  the  text  comments  made 
before  my  class  on  recent  passing  cases,  and  inserting 
twenty  three  new  lectures,  three  given  at  the  College  of 
Physicians,  and  the  rest  in  the  theater  of  St.  Mary's 
Hospital  School. 


624156 


vi  PREFACE  TO  THE  FOURTH  EDITION. 

While  that  edition  was  in  the  press,  I  was  struck  down 
by  a  dangerous  illness,  and  have  been  out  of  work  nearly 
eighteen  months.  On  my  return,  by  God's  grace,  to 
health  and  labor,  I  find  it  sold  off,  and  a  new  one  called 
for  before  I  have  again  occupied  the  teacher's  chair.  I 
have,  therefore,  no  fresh  matter  to  offer,  and  must  content 
myself  with  a  thorough  revision,  and  the  addition  of  an 
index  unavoidably  omitted  last  year. 

It  will  be  seen  that  many  of  the  "  Lectures,"  as  set 
before  the  reader,  combine  materials  orally  delivered  at 
several,  and  often  at  distant,  times.  These  are  short  clini- 
cal commentaries  on  cases,  made  still  shorter  by  the  omis- 
sion of  much  elementary  instruction  on  diagnosis,  only 
suited  to  students.  The  fragments  are  here  united  under 
subjects,  and  to  avoid  chronological  confusion  the  date  of  its 
viva  voce  production  is  placed  at  the  head  of  each  portion. 
I  trust  the  disjointed  aspect  thus  given  will  be  pardoned, 
as  we  pardon  roughnesses,  inexcusable  to  the  finished 
works  of  the  studio,  in  a  portfolio  of  sketches  made  on  the 
spot,  out  of  consideration  for  the  vividness  which  drawing 
from  nature  only  can  give. 

T.  K.  C. 

22b,  Brook  Street,  Grosvexor  Square  ; 
October,  1865. 


SUBJECTS  OF  LECTURES. 


PAGE 

I. 

Death  and  Life  .            .            .            .            .13 

II. 

Disease  and  Cure 

30 

III. 

Formation  of  Mucus  and  Pus   , 

54 

IV. 

Ditto     .... 

62 

V. 

Ditto     .            .            .        '    . 

72 

VI. 

Typh-Fever 

86 

VII. 

Ditto     . 

106 

VIIL 

Ditto     . 

111 

IX. 

Ditto     . 

117 

X. 

Smallpox 

132 

XI. 

Rheumatic  Fever 

144 

XII. 

Ditto     . 

156 

XIII. 

Ditto     .... 

164 

XIV. 

GONORRHCEAL  RHEUMATISM 

168 

XV. 

Pericarditis 

.     181 

XVI. 

Pleurisy  . 

.     194 

XVII. 

Hydrothorax 

.     203 

XVIII. 

Acute  Laryngitis 

.     221 

XIX. 

Capillary  Catarrh 

.     230 

XX. 

Pneumonia 

.     238 

XXI. 

Ditto     . 

.     251 

XXII. 

Emphysema  op  the  Lungs 

274 

XXIII. 

Pulmonary  Consumption 

.     288 

XXIV. 

Thoracic  Aneurism 

.    309- 

VUl 


SUBJECTS  OF  LECTURES. 


XXV.  Disease  of  the  Heart    . 
XXVI.  Purpura  .      *      . 
XXVII.  Anvemia    . 
XXVIII.  Prominence  op  Eyeballs 
XXIX.  Atrophy  of  Muscles 
XXX.  Chorea     . 
XXXI.  Epilepsy  . 
XXXII.  Hysteria  . 

XXXIII.  Spinal  Paralysis 

XXXIV.  Sciatica    . 
XXXA^.  Albuminuria 

XXXVI.      Ditto     . 
XXXVII.  Ascites      . 
XXXVIII.  Diabetes  . 
XXXIX.  Mortification 

XL.  Importance  of  the  Digestive  Organs 
rapeutics 
XLL  Indigestion  in  General  . 
XLII.  Slow  Digestion  and  Acidity 
XLIII.  Pain  in  the  Stomach 
XLIV.  Eructation  and  Vomiting 
XLV.  Diarrh(ea 

XL VI.    COSTIVENESS  AND  CONSTIPATION 

XLVII.  Dietetics  . 
XLVIII.  Corpulence 
XLIX.  On  Pepsine 
L.  On  Alcohol 
LI.  On  Bloodletting 
LII.  Review 
L'Envoi 


IN  The- 


CHAMBERS'    LECTURES. 


LECTURE  I. 

DEATH  AND  LIFE. 

Reasons  for  introductory  lectures — Decay  of  dead  bodies^  or 
Death — Decay  of  living  bodies,  or  Life — Life  cannot  be  in 
excess — Health,  death,  and  disease,  contrasted —  Partial  death 
as  exhibited  in  disease,  viz.,  in  degenerations,  in  hypertrophies, 
in  malignant  tumors,  in  catarrh,  in  boil  and  abscess,  in  fever 
and  zymotic  diseases,  in  ansemia,  in  tuberculosis — Classification 
of  diseases — The  restorative  direction  of  modern  medicine. 

{Introductory  Clinical  Lectures  at  St.  Mary's  Hospital,  delivered 
October  4,  18G1,  and  October  2,  1862.) 

Before  I  enter,  as  a  teacher  of  clinical  medicine,  upon  my 
duty  of  showing  you  how  to  read  the  lessons  which  are  spread 
out  before  your  eyes  in  the  hospital  wards,  it  is  my  custom  to 
give  you  an  introductory  lecture.  I  think  this  saves  time  in  the 
end,  for  '•''claudus  in  vid  antevertit  cursorem  extra  viaiii,"  as 
Bacon  tells  us,  and  my  object  is  to  show  you  the  way.  Doubt- 
less all  your  past  professional  studies  have  been  in  a  manner  in- 
troductory to  this  crowning  study;  your  anatomy,  and  chemistry, 
and  physiology,  and  the  systematic  principles  of  medicine  learnt 
under  me  and  my  colleagues,  have  led  up  to  this  end.  But 
I  wish  shortly  to  recall  to  your  memory  what  points  in  those 
studies  of  life  and  death  have  the  most  special  bearing  on  the 
2 


14  DEATH  AND  LIFE. 

matter  in  hand,  and  to  show  how  a  consistent  theory  of  thera- 
peutics may  be  built  up  from  them. 

It  is  true  that  there  are,  and  always  have  been,  practitioners 
who  declaim  against  theories  altogether,  who  even  boast  that 
they  can  do  without  them,  and  think  them  useless,  not  consider- 
ing that  to  express  such  scorn  is  as  if  we  should  be  proud  of  not 
knowing  what  we  do  when  we  act,  or  what  we  say  when  we  talk. 
To  reason  at  all  is  to  theorize;  no  one  without  theorizing  can 
direct  a  method  of  cure  to  a  sick  person  except  at  haphazard. 
As  a  matter  of  fact,  none  of  these  objectors  ever  do  prescribe 
without  theorizing  about  either  the  individual  suJBferer  or  the 
class  to  Avhich  they  refer  his  sickness,  though  not  always  able 
to  put  their  theory  into  words.  In  short,  the  want  of  a  guiding 
principle  to  connect  the  loose  facts  of  daily  experience  has  at 
all  times  been  felt. 

From  this  practical  need  have  been  bred  the  many  systems  of 
therapeutics  stamping  their  mark  from  time  to  time  on  the  his- 
tory of  our  art.  They  have  sprung  from  the  brains  of  working 
men  at  the  bedside,  not  from  philosophers  in  their  closets.  Their 
adopters  have  not  necessarily  any  strong  faith  in  their  truth  or 
universal  applicability;  but  the  heart  wearies  for  a  chain  to  link 
together  the  scattered  fragments  of  knowledge — a  string  for  its 
pearls;  it  must  have  an  idea  on  which  to  codify  the  laws  of 
action. 

It  would  be  a  long  task  to  quote  the  curious  systems  founded 
on  imperfect  data,  but  numbering  their  hosts  of  followers  in 
former  ages,  which  have  been  given  up  as  false  and  dangerous ; 
I  do  not  wish  twice  to  slay  the  slain.  I  shall  content  myself 
with  putting  before  you  that  which  influences  me  in  my  prac- 
tice, to  which  I  now  proceed. 

Man's  body  may  be  likened  to  a  stately  mansion,  made  of 
beauteous  but  very  perishable  materials,  all  of  which  are  always 
needing  repairs  to  keep  up  the  shapeliness  and  usefulness  of  the 
building.  But  not  all  in  equal  degrees;  some  of  the  walls  may 
stand  unaided  for  years,  while  other  parts  may  want  almost 
hourly  looking  after.  When  the  owner  leaves  the  dwelling  the 
repairs  cease,  and  then  we  see,  not  all  at  once,  but  one  after 


DEATH  AND  LIFE.  15 

another,  the  materials  falling  into  ruin.  It  will  serve  a  purpose 
in  my  argument  to  think  over  the  several  steps  of  this  ruin  for 
a  few  minutes. 

Already  while  the  soul  is  withdrawing  we  know  that  changes 
begin,  very  obvious  to  even  the  most  superficial  observer.  These 
changes  are  mostly  due  to  the  loss  of  water  by  evaporation. 
The  eyeball  loses  its  brilliancy  and  gets  dry  and  flat,  the  features 
shrink,  the  gloss  leaves  the  hair  and  skin.  All  this  goes  on  all 
the  more  rapidly  after  decease,  and  then  we  hide  our  dead  out 
of  our  sight,  and  the  future  fate  of  the  body  is  less  familiar  to 
us;  we  must  search  for  exceptional  cases  or  special  observations 
if  we  want  to  know  what  happens.  These  we  may  cull  from 
sundry  independent  sources.  Here  is  one  which  old  barbarous 
manners  afford  us.  "Rizpah  the  daughter  of  Aiah,  the  concu- 
bine of  Saul,"  watched  for  the  six  summer  months,  from  "the 
beginning  of  barley-harvest"  in  April,  to  the  rainy  season  in 
October,  "  till  water  dropped  upon  them  out  of  heaven,"  to  guard 
the  corpses  of  her  murdered  kinsmen  from  the  beasts  of  prey. 
So  long  under  the  sky  of  Palestine  did  they  hold  out  a  quarry 
for  the  wild  dogs  and  vultures. 

In  a  moister  air  decay  is  quicker,  but  still  not  so  quick  as  is 
often  supposed.  Here  is  another  observation  redolent  of  the 
refinements  of  modern  science.  The  notes  made  by  M.  Devergie* 
on  the  bodies  at  the  Morgue  at  Paris,  show  that  for  two  months 
and*a  half  after  decease  the  muscular  structures  still  keep  their 
natural  forms  and  hues.  Up  to  three  months  and  a  half,  the 
scalp,  eyelids,  and  nose  so  far  retain  their  ordinary  feature  that 
the  age  of  the  person  may  be  told..  It  is  four  months  and  a  half 
before  complete  destruction  of  the  face  occurs,  or  the  bones 
become  brittle,  and  the  bulky  muscles  of  the  neck  and  thighs 
are  converted  into  adipocere.  So  that  we  may  call  three  months 
and  a  half  a  short  time  to  be  occupied  by  the  decomposition  of 
a  human  body.  So  long  does  flesh  last  as  flesh,  and  tissue  tissue, 
and  is  not  melted  into  its  mother  earth. 

Let  us  come  forth  quickly  from  these  ghastly  scenes  of  the 
charnel-house  to  the  joyous  bustle  of  brimming  life,  and  ask  how 

*  Devergie,  "Medecine  Legale,"  t.  ii,  chap.  v. 


16  DEATH  AND  LIFE. 

long  it  takes  not  a  dead  but  a  living  body  to  decay?  "A  living 
body  decay?"  Yes,  in  truth;  but  Avhereas  in  the  former  case  it 
was  a  thing  to  make  men  shudder,  the  fading  of  a  long-loved 
image,  the  tearing  up  of  a  fair  garment,  the  fall  of  a  darling 
home,  the  violation  of  a  worshipped  shrine,  the  forcible  divorce 
from  our  nearest  and  dearest — it  is  all  this  and  more — in  the 
latter  it  is  associated  with  the  fullest  fruition  of  all  that  is  joyous 
in  existence,  the  bounding  pulse,  the  free-drawn  breath,  the 
swelling  chest,  the  thrilling  feel  of  health,  the  highest  uses  of 
mind  and  body.  Decay  is  more  truly  a  part  of  life  than  it  is 
of  death ;  for  it  goes  on  unstayed  through  the  whole  of  corporeal 
being;  whereas,  after  dissolution,  it  gradually  ceases,  and  ends 
its  work  with  the  reconversion  of  the  organic  particles  into 
eternally  changeless  elements.  The  most  living  body  is  the 
most  active  in  decay;  the  more  bodily  and  mental  vigor  are  dis- 
played, the  more  quickly  do  the  various  tissues  melt  down  into 
substances  which  are  without  delay  removed  by  the  excreting 
organs.  The  more  the  blacksmith  toils  with  his  arms  and  the 
more  the  statesman  with  his  brain,  the  heavier  bulk  of  carbon, 
nitrogen,  oxygen,  and  hydrogen  is  thrown  out  by  lungs,  liver, 
skin,  and  kidneys.  Do  they  then  wear  out  by  this  constant  use, 
friction,  and  drain?  No,  no — the  more  bricks  are  removed  from 
the  old  wall,  the  more  new  bricks  will  a  good  builder  put  in ; 
and  so,  provided  that  the  supply  is  suflScient,  and  that  the  builder 
is  a  good  one — the  more  rapid  the  drain — the  newer  and  stronger 
and  fitter  for  its  uses  will  the  body  become. 

But  I  will  leave  generalities  and  try  to  represent  in  figures 
how  long  it  takes  by  living  decay  for  the  living  body  to  drain 
away,  and  to  have  its  substance  renewed.  In  the  grim  details 
which  I  recalled  to  your  memory  at  the  beginning  of  this  lec- 
ture, the  nitrogenous  or  fleshy  parts  were  most  accounted  of  and 
especially  named  as  giving  shape  and  the  general  look  of  a  man 
to  the  melting  corpse.  So  of  the  nitrogenous  parts  we  will  now 
speak — How  long  are  they  in  being  removed  by  vital  decom- 
position? 

We  may  reckon  with  Drs.  Bidder  and  Schmidt*  that  the  body 

*    '-Die  Verdauungssiifte  und  der  Stoffwechsel,"  p.  400. 


DEATH  AND  LIFE.  17 

of  <i  mammal  contains  35"45  grammes  of  nitrogen  per  kilogramme; 
and,  therefore,  tLat  an  animal  of  130  lb.  (which  is  the  mean 
weight  of  a  man)  contains  upwards  of  4-6  lb.  of  nitrogen. 

Then  again,  taking  our  numbers  from  an  equally  sound  and 
independent  source,  we  may  reckon  with  Baron  Liebig*  that  the 
liquid  and  solid  excreta  of  a  man  b}"  kidneys  and  bowels  for  a 
year  contain  16'41  lb.  of  nitrogen,  or  for  three  months  and  a 
half  4'7  lb.  of  nitrogen. 

That  is  to  say,  in  three  months  and  a  half  a  quantity  of  nitro- 
gen is  remoA'^ed  by  excretion,  or  vital  decay,  equal  to  the  quan- 
tity of  nitrogen  in  the  whole  mass  of  the  chief  nitrogenous  tissue. 

What  attractions  has  this  term  of  three  months  and  a  half  for 
us? — what  memories  does  it  rouse?  Why,  this  was  the  very 
time  we  fixed  upon  for  the  fleshy  framework  of  the  corpse  to 
melt  away  in.  Here  is  a  pregnant  fact,  a  light  thrown  on  the 
mysteries  of  nature  from  a  most  unpromising  source!  Dead 
flesh  and  living  flesh  last  as  nearly  as  possible  the  same  time — 
the  former,  if  anything,  rather  the  longer.  As  far  as  we  can 
judge,  the  albiuiien,  fibrin,  gelatin,  &c.,  which  make  up  the  live 
body,  difl"er  in  nowise  from  the  same  matters  dead;  they  are 
liable  to  the  same  changes,  aftected  by  the  same  reagents,  and 
naturally  are  resolved  into  their  elements  in  the  same  time;  just 
as  the  marble  in  the  Apollo  Belvidere  is  to  a  mineralogist  the 
same  stone  as  it  was  in  the  quarry,  liable  to  the  same  accidents 
and  possessed  of  the  same  properties,  though  temporarily  en- 
dowed with  a  diff"erent  value,  and  made  god-like  by  its  adventi- 
tious form. 

What,  then,  raises  to  the  rank  of  living  creatures,  and  clothes 
with  loveliness  the  masses  of  organic  matter  which  are  growing, 
moving,  breathing,  thinking,  all  around  us?  It  is  the  power  of 
the  individual  Life  to  create  its  own  individual  Form.  A  man 
has  no  right  of  property  over  the  particles  of  his  body,  except 
so  long  as  they  remain  particles  of  his  body  and  retain  his  shape. 
He  hardly  calls  his  the  snippings  of  his  hair  or  the  parings  of 
his  nails,  much  less  the  carbonic  acid  he  exhales  from  his  lungs 
or  skin;  all  that  he  throws  off  is  by  common  consent  claimed  as 

*  Liebig"s  "Chemistry  of  Agriculture  and  Physiology,"  part  i,  chap.  ix. 


18  DEATH  AND  LIFE. 

a  perquisite  by  the  public;  and  the  battle-fiehls  which  he  has 
fertilized  with  his  blood  enrich,  not  him,  but  the  peaceful  farmer. 
Yet  as  long  as  these  organic  constituents  retain  the  form  im- 
pressed upon  them  by  the  individual  life,  they  are  mote  truly 
his  than  any  portion  of  his  inheritance. 

A  conjectural  theory  has  been  hazarded  that  Life  mysteri- 
ously endows  living  matter  with  a  defensive  virtue,  which  en- 
ables it  to  resist  the  chemical  and  other  powers  acting  regularly 
on  inorganic  and  dead  matter.  The  most  notable  instance  cited 
is  the  stomach,  which  digesting  everything  else  is  not  itself 
digested.  This  consumer  of  flesh  is  itself  made  of  flesh,  yet  is 
not  consumed.  An  answer  seems  given  to  the  witty  philoso- 
pher, who  on  hearing  an  alchemist  boast  his  discovery  of  a  uni- 
versal solvent,  inquired  "In  what  vessel  do  you  keep  it?"  The 
stomach  says  (it  has  been  in  the  habit  of  saying  wise  things 
even  before  the  time  of  Menenius  Agrippa),  "In  a  vessel  like 
me,  which  is  destroyed  indeed  continuously,  but  is  continuously 
rebuilt."  Recent  researches  show  that  livins;  matter,  such  as 
parts  of  living  animal  swallowed  for  instance,  is  dissolved  by 
the  gastric  juice,  and  moreover  that  its  own  epithelial  coat  is 
destroyed,  but  is  immediately  replaced  by  a  new  one.  By  this 
activity  of  growth  (the  idea  of  the  impudent  members  calling 
the  belly  lazy!),  and  by  a  constantly  flowing  supply  of  alkaline 
blood  to  neutralize  any  of  the  acid  secretion  which  might  pene- 
trate too  deep,  it  retains  the  same  shape  for  threescore  years 
and  ten.  But  it  has  no  privileged  immunity  against  the  solvent 
it  makes. 

It  is,  then,  the  Form  which  constitutes  the  Self;  and  it  is  not 
the  changing,  decaying  matter  which  "was  mine,  is  his,  and 
may  be  slave  to  thousands."  The  organic  materials  are  the 
property  of  the  form  only  so  long  as  it  retains  them,  and  no 
longer — they  are  a  floating  capital.  Over  the  innate  essential 
nature  of  the  material  it  has  no  control.  Life  cannot  make  the 
brute  materials  which  it  uses  live  longer  than  that  which  it  leaves 
unused,  but  it  has  the  power  of  making  them  anew,  and  building 
them  up  into  a  certain  shape  for  the  time  they  are  made  to  last. 
In  short.  Life  rests  on  the  metamorphosis  or  Renewal  of  the 


DEATH  AND  LIFE.  19 

body;  as  this  renewal  is  more  thorough,  the  individual  is  more 
perfect,  and  fulfills  better  and  more  completely  the  duties  of  its 
position.  If  it  stops  altogether,  the  body  is  no  longer  living. 
If  it  partially  stops,  the  order  of  normal  phenomena  is  disarranged, 
and  ease  is  expelled — there  is  a  state  which  we  call  '' dis-order'' 
or  '"c^/s-ease." 

To  speak,  therefore,  of  "a  superabundance  of  life,"  or  of  an 
"excess  of  vital  action,"  is  a  contradiction  in  terms.  There 
cannot  be  too  active  .a  metamorphosis  of  the  tissues  into  their 
complete  form,  for  the  fresher  their  organic  constituents,  the 
more  serviceable  they  are,  and  the  longer  duration  they  have 
before  them.  There  cannot  be  too  close  an  adherence  to  that 
typical  form  which  it  is  the  business  of  metamorphosis  to  keep 
up,  any  more  than  there  can  be  too  exact  an  obedience  to  law 
and  order. 

The  most  active  metamorphosis  of  the  body  possible,  the  high- 
est possible  development  of  life  in  every  part,  is  Health. 

The  complete  cessation  of  metamorphosis  is  Death. 

The  partial  cessation,  or  the  exhibition  of  materials  in  an  in- 
complete form,  however  copious  they  may  be,  is  Disease. 

In  death  the  flesh  goes  on  being  decomposed  as  during  life  ; 
but  not  being  renewed,  the  form  is  lost  entirely.  In  disease, 
decomposition  goes  on,  but  renewal  flags,  the  incomplete  tissues 
are  retained  as  part  of  the  imperfect  body — a  sort  of  "  death  in 
life" — and  are  rightly  termed  by  the  pathologist  "degenerate." 
They  are  generated,  but  not  re-generated ;  they  are  generated 
in  an  inferior  mould  of  form. 

Take  as  an  example  what  happens  sometimes  to  voluntary 
contractile  fiber.  We  all  know  that  if  an  animal's  limbs  are 
duly  employed,  the  muscles  keep  up  their  shape  and  their  vigo- 
rous power  of  contraction  ;  their  flesh  is  of  a  rich  bright  red 
color  when  the  animal  is  fully  grown,  and  is  firm  and  elastic. 
Examine  it  under  a  microscope,  and  you  find  it  made  up  of  even 
parallel  fibers,  each  fiber  seeming  to  be  engraved  over  Avith 
delicate  equidistant  cross-markings,  like  a  measuring-tape  very 
minutely  divided.     The  more  the  muscle  has  been  used  in  a  well- 


20  DEATH  AND  LIFE. 

nourished  frame,   the    more  closely  it  conforms  to  the  typical 

specimen  of  the  physiologist : 

"  Use,  use  is  life ;  aad  be  most  truly  lives 
Who  uses  best." 

But  suppose  this  muscular  fiber  has  been  unworked — suppose 
it  is  in  the  biceps  of  an  Indian  fakeer,  who  has  fastened  his  arm 
upright  till  it  has  become  motionless,  or  in  the  gluteus  of  a  sold- 
ier's amputated  leg,  or  the  calf  of  a  Chinese  belle,  or  in  a  paral- 
yzed limb — then  the  flesh  is  quite  different  in  aspect ;  it  is  flabby 
and  inelastic,  of  a  pale  yellowish  hue,  and  makes  greasy  streaks 
on  the  knife  that  cuts  it.  Sometimes  even  all  traces  of  fibers 
have  disappeared,  and  it  is  converted  into  an  unhealthy  fat. 
Sometimes  you  may  trace  fibers  under  the  microscope,  but 
their  outline  is  bulging  and  irregular,  the  cross-markings  are 
wanted,  and  you  see  instead  dark,  refracting  globules  of  oily 
matter  in  them.  In  short,  the  muscle  is  degenerating  into  fat, 
retaining  in  a  great  measure  its  shape,  but  losing  its  substance. 
Such  is,  by  God's  law,  the  penalty  of  not  using  His  gifts  for  four 
or  five  months. 

Now  go  back  to  our  first  sepulchral  illustrations.  M.  Devergie 
found  that  in  a  period  of  between  four  and  five  months  the  flesh 
of  a  corpse  is  converted  into  a  substance  technically  termed 
"  adipocere  :"  an  oleaginous  substance  between  fat  and  wax — an 
artificial  fat  the  result  of  chemical  decomposition.  What  is  this 
but  precisely  that  which  happens  to  the  disused  muscles  in  the 
cases  quoted  ?  At  the  Morgue,  a  continuous  stream  of  water 
washed  away  the  fetid  gases  from  the  subject  of  M.  Devergie's 
observations,  and  in  the  living  body  destructive  metamorphosis 
and  excretion  remove  the  more  directly  noxious  particles ;  in 
both  there  remains  the  same  oleaginous  residuum. 

The  instance  chosen  of  diseased  structure  was  purposely  an 
extreme  one  ;  but  even  there,  a  very  high  degree  of  partial 
death  was  seen  not  to  be  inconsistent  with  life.  A  less  degree 
is  not  inconsistent  even  with  active  usefulness.  Look  at  many 
a  man  whom  his  physician  knows  to  have  a  weak  or  slightly 
dilated  heart ;  he  goes  on  with  his  profession,  mixes  in  society, 
enjoys  his  quiet  pleasures,  and  may  even  insure  his  life  by  pay- 


DEATH  AND  LIFE.  21 

ing  an  extra  premium.  Yet  if  an  accident  at  any  time  should 
cut  him  off  suddenl}'-,  the  muscuhir  tissue  of  the  heart  will  be 
found  pale  and  soft,  while  under  the  microscope  the  fibers  are 
seen  deficient  in  clear  outline  and  in  cross-markings,  and  exhibit 
here  and  there  minute  specks  of  that  fatty  degeneration  which 
was  so  conspicuous  to  the  naked  eye  in  M.  Devergie's  subjects 
and  in  the  completely  palsied  limb.  The  more  dilated  and  the 
more  weak  the  heart,  the  more  widespread  is  this  degeneration. 
Yet  enough  of  active  structure  is  left  to  carry  on  the  work  of 
the  heart,  and  perhaps  to  prolong  life  to  its  allotted  three-score 
years  and  ten. 

A  close  copy  of  the  pathological  process  may  be  made  by 
soaking  a  piece  of  muscle,  say  from  a  healthy  sheep's  heart,  in 
a  running  stream,  in  weak  spirits  and  water,  or  in  nitric  acid 
and  water,  for  a  few  weeks,  when  sections  made  from  time  to 
time  will  exhibit  the  several  stages  of  fatty  degeneration,  from 
the  minute  specks  in  the  scarcely  altered  muscle  up  to  complete 
conversion  into  adipocere.* 

Remark  in  these  cases  of  fatty  degeneration  or  decay  that  the 
substance  which  replaces  the  highly  organized  animal  matter  is 
not  utterly  inorganic.  It  is  less  organized  and  less  organizable, 
but  still  capable  of  being  called  alive.  Of  our  living  bodies  fat 
is  a  part  and  a  necessary  part ;  but  still  it  is  not  capable  of  per- 
forming the  highly  vital  duties  of  muscle,  of  being  as  th-oroughly 
alive.  Degenerated  products,  therefore,  so  long  as  they  form 
part  of  the  body,  may  still  be  said  to  be  alive,  but  less  alive  than 
the  normal  tissues  they  replace  ;  and  degenerate  growth  may  be 
justly  described  as  "diminished  life," — or  in  the  Avords  I  lately 
used,  "  partial  death."  Degeneration,  in  short,  is  a  more  or  less 
relapse  into  a  lower  and  lower  form  of  organic  life,  and  exhibits 
itself  therefore  in  a  variety  of  grades  and  amounts.  Occurring 
in  various  parts,  it  occasions  three-quarters  of  the  chronic  ill- 
nesses which  give  work  to  the  physician. 

Let  it  be  well  understood  that  these  half-living  tissues  are  by 
no  means  necessarily  lessened  in  size.     A  battered  and  renovated 

*  Figured  in  "  Medico-Chirurgical  Transactions,"  vol.  xxxiii,  plate  v,  in  illus- 
tration of  a  paper  by  Dr.  Quain. 


22  DEATH  AND  LIFE. 

vessel  is  often  much  bulkier  than  a  strong  new  one ;  and  in  the 
same  way  these  under-nourished  parts  are  often  enlarged,  and 
so  have  been  wrongly  supposed  to  be  over-nourished.  They 
often  attain  a  most  cumbersome  weight  and  bigness  without  really 
containing  tissue  enough  to  do  their  work.  They  become,  in 
truth,  a  foreign  substance.  Sometimes  they  acquire  what  seems 
like  a  parasitic  life,  and  grow  as  if  independent  of  the  body 
which  they  inhabit.  Then  you  justly  look  upon  them  with  a 
peculiarly  unfavorable  eye,  and  call  them  by  the  epithet  "  mal- 
ignant." Cancer  is  the  best-known  example  to  quote  ;  and  you 
who  have  watched  its  deadly  quickness  of  growth  are  perhaps 
wondering  that  it  should  be  put  forth  as  an  instance  of  lessened 
vitality.  But  Avatch  further  with  the  mind  and  not  with  the 
eye  only  ;  you  will  see  that  the  abnormal  tissue  never  gains  the 
higher  characteristics  of  life,  never  puts  on  the  form  of  the  part 
invaded,  nor  performs  its  duties.  Moreover  that  half-life,  so 
easily  acquired  and  so  easily  multiplied,  is  also  easily  lost.  The 
very  tendency  to  die  and  to  ulcerate  is  one  of  the  chief  dangers 
in  which  cancer  puts  your  patient. 

But  we  are  now  driven  to  seek  our  illustrations  among  these 
dreadful  sorrows  of  our  kind,  when  we  can  find  them  in  less  pain- 
ful scenes.  Every  one  connects  cancer  and  degeneration  with 
death ;  but  perhaps  it  is  not  quite  such  a  familiar  idea  to  see 
partial  death  in  a  cold  in  the  head  or  relaxed  throat.  However 
much  you  may  smile  at  the  notion,  it  is  a  true  one ;  and  I  should 
advise  your  taking  the  next  chance  which  a  catarrh  gives  you  of 
seeing  the  truth  and  its  bearings.  It  is  almost  worth  while  to 
catch  one  on  purpose,  so  valuable  is  the  lesson.  And  perchance 
your  smile  may  become  a  grave  and  thoughtful  one,  when  you 
reflect  on  the  mysteries  of  life  ;  when  you  think  that  the  slight 
inconvenience  you  are  bearing  is  of  the  same  nature  as  that 
which  divorces  soul  and  body,  a  distant  and  indistinct  foretaste 
of  that  dread  cup  which  we  must  all  one  day  drain.* 

*  And  perchance  also  this  may  be  a  useful  meditation,  not  only  for  medical 
men,  but  also  (as  is  remariied  in  an  article  on  "  The  Renewal  of  Life,"  in  the 
"  Medico-Chirurgical  Review''  for  July,  1863)  for  amateur  tamperers  with  life, 
■who  in  their  zeal  without  knowledge  are  so  fond  of  remedying  minor  bodily 

ills. 


DEATH  AND  LIFE.  23 

Look  at  your  catarrhal  throat  in  a  mirror — what  do  you  see  ? 
The  surface  red,  puffy,  and  with  the  component  parts,  such  as 
the  uvula,  enlarged.  There  is  also  poured  out  a  quantity  of 
slimy  material,  which  you  well  know  by  the  name  of  mucus.  At 
first  you  may  be  disposed  to  cry,  "  Surely  here  is  an  active  busi- 
ness going  on  ;  everything  seems  much  more  lively  than  usual ; 
life  is  increased,  not  diminished."  Not  so  fast — examine  in  a 
microscope  a  little  of  this  mucus,  and  you  will  find  it  made  up  of 
minute  balls  of  transparent  jelly  with  a  granular  aspect,  techni- 
cally called  "exudation-globules,"  "mucous  globules,"  and  "pus- 
globules,"  floating  quite  free,  and  rolling  over  and  over  without 
any  tendency  to  adhere  together.  Are  these  bodies  a  new 
creation,  something  which  an  inflamed  membrane  can  produce, 
while  a  healthy  one  lacks  the  power  ?  are  they  evidences  of  an 
additional  life-force  ?  By  no  means  ;  for  they  have  been  identi- 
fied with  those  elementary  forms  of  nascent  life  by  which  all  or- 
ganic matters  grow  ;  they  are  young  cells,  or  rather  nuclei.* 
They  are  the  form  assumed  by  all  liquid  living  material  which 
under  the  influence  of  life  is  being  transformed  into  a  solid :  they 
are  an  infant  tissue  strangled  in  its  birth.  Instead  of  uniting 
into  a  continuous  web  to  clothe  with  epithelium  the  surface  of  the 
membrane,  they  float  off  helpless  from  deficient  vitality.  The 
business  of  mucous  membranes  is  to  be  covered  with  epithelium, 
not  to  throw  off  mucus  ;  and  when  they  are  doing  the  latter,  they 
are  so  far  forth  in  a  state  of  diminished  life. 

But  you  may  ask,  what  is  that  redness  and  that  throbbing  of 
the  inflamed  part?  do  not  they  show  an  increased  circulation  of 
the  vital  fluid,  and  therefore  increased  life?  Quite  the  contrary, 
for  the  membrane  is  red  because  its  blood-vessels  are  relaxed 
and  dilated  from  loss  of  vital  elasticity  ;  the  blood  sticks  in  them 
as  water  in  a  bulged  pipe ;  and  the  arteries,  pressed  upon  from 
behind  by  the  heart,  throb  because  the  obstruction  impedes  their 
action. 

*  The  indentification  of  young  epithelium  and  pus-cells  was  some  years  ago 
amusingly  made  out  by  M.  Lebert,  who,  in  plate  iii,  figs.  3  and  6,  of  the  atlas  to 
his  "  Physiologie  Pathologique,"  places  them  in  opposition,  with  the  intent  of 
pointing  out  their  differences,  but  with  the  result  of  showing  their  indentity. 


24  DEATH  AND  LIFE. 

"But  the  pain, — docs  not  that  show  that  the  vital  poAver  of 
sensibility  is  increased?  I  cannot,  in  general,  feel  that  I  have 
got  a  throat;  and  now  I  am  reminded  most  disagreeably  of  the 
fact."  No;  pain  docs  not  indicate  an  increase  of  proper  sensi- 
bility ;  in  this  case  it  is  associated  with  a  very  marked  decrease. 
During  your  catarrh  the  lining  membrane  of  the  fauces  loses  its 
delicate  appreciation  of  flavors — everything  is  equally  nasty,  un- 
less there  is  a  pungency  in  it  too  powerful  to  be  pleasant  to  the 
healthy  taste.  And  it  is  wanting  also  in  common  sensibility  ; 
for  it  does  not  distinguish  the  shape  or  size  of  morsels  swallowed, 
all  of  which  feel  equally  large  and  awkward. 

Or  you  may  get  a  whitlow  on  your  finger,  or  a  boil,  and  study 
how  the  nail  is  stayed  in  its  growth,  and  the  skin  is  killed;  while 
the  materials  intended  to  renew  them  are  checked  in  their  de- 
velopment, and  go  to  be  deposited  as  pus,  a  concentrated  form  of 
half-vitalized  fluid,  very  similar  in  every  respect  to  mucus.* 
And,  like  your  catarrhal  throat,  your  inflamed  finger-tip  is  want- 
ing in  sensibility  :  try  it,  and  you  will  find  for  any  delicate  work, 
such  as  feeling  tlie  fine  lines  of  a  copper-plate,  or  the  flaws  in  a 
polished  surface,  it  fails  in  its  duty.  Pain,  in  short,  is  the  bro- 
ther of  death  ;  a  painful  part  is  never  performing  its  whole  vital 
functions — it  is  partially  defunct. 

The  same  partial  death,  which  has  been  hitherto  described  as 
constituting  the  various  diseased  states  of  the  solid  structures  of 
the  body,  may  also  attack  the  fluids  ;  and  in  them,  as  in  the 
solids,  it  may  show  it  itself  either  as  a  destructive  relapse  into  a 
less  organic  life, or  as  an  arrest  of  development.  The  poison  of 
fever,  for  example,  destroys  and  renders  useless  as  nutriment 
some  constituents  of  the  blood  ;  the  insufiicient  blood  is  circulated 
to  all  parts  of  the  body,  causing,  not  local  pain,  but  general 
malaise  by  its  deficient  vitality.  The  half-poisoned  tissues  allow 
the  poisoned  material  to  ooze  through  them,  causing  diarrhoeas, 
haemorrhages,  purple  blotches  on  the  skin,  and  a  general  stain- 
ing of  the  whole  body  of  a  dusky  hue.     If  the  quantity  of  blood 

*  On  the  pus  formation  in  connective  tissue,  see  Virchow's  "  Cellular  Patho- 
logy," fig.  137,  and  the  text  adjoining,  and  the  Lumleian  lectures  which  follow 
in  this  present  volume. 


DEATH  AND  LIFE.  25 

poisoned  be  moderate,  it  can  be  spared ;  it  is  carried  off  gradu- 
ally by  excretions,  and  its  place  is  filled  up  by  new  blood.  But 
if  the  rare  case  happens  of  so  much  being  poisoned  at  once  that 
too  little  remains  to  carry  on  the  business  of  the  body,  then  death 
occurs  by  sudden  shock ;  or  if  there  be  an  insufficient  supply 
of  material  to  take  the  place  of  the  blood,  the  vitality  wanes 
away  more  slowly.  And  as  its  loss  occurs  more  slowly,  some 
one  part  more  than  another  is  usually  affected ;  there  is  inflam- 
mation— that  is,  local  death — of  the  digestive  viscera,  or  of  the 
lungs,  or  of  the  brain,  and  the  patient's  disease  is  allotted  by 
name  to  that  last  clause.  And  thus  in  fever,  the  blood  relapses 
into  a  less  organic  form  through  its  vitality  being  destroyed  by  a 
morbid  poison. 

Let  us  next  look  for  an  instance  of  imperfect  life  in  the  blood 
occasioned  by  arrest  of  development.  You  are  all  probably 
familiar  with  the  common  condition  we  call  anaemia.  The  word 
literally  means  "bloodlessness,"  but  in  reality  relates  rather  to 
deficient  quality  than  deficient  quantity.  The  circulating  fluid 
cannot  but  fill  the  closed  vessels,  but  it  is  wanting  in  the  most 
highly  organized,  the  most  truly  living  of  its  constituents.  It  is 
pale,  from  the  diminished  numbers  of  those  floating  red  globules 
which  give  its  florid  hue.  The  capital  of  red  globules  is  by  far 
the  most  important  portion  of  the  blood  ;  so  much  so,  that  it  may 
be  taken  as  a  direct  measure  of  corporeal  and  mental  vigor ;  a 
man  has  a  larger  proportion  than  a  woman,  a  strong  man  than 
a  weak  man,  an  adult  more  than  a  youth  or  an  elder,  a  patient 
after  recovery  more  than  during  his  sickness  of  whatever  kind, 
a  horse  in  high  condition  more  than  when  brought  from  grass. 
Spite  of  its  importance,  we  find  to  our  surprise  that  this  floating 
capital  may  be  largely  encroached  upon  without  bankruptcy.  For 
example,  Dr.  Andral  has  analyzed  the  blood  of  a  patient  with 
anaemia,  where  the  blood-globules  amounted  to  less  than  39  parts 
in  1000,  whereas  their  natural  proportion  should  be  at  least  120 
parts  in  1000.  More  than  two-thirds  of  this  constituent  were 
missing  !  Yet  the  patient  was  living,  and  very  likely  quite  re- 
covered in  the  end  if  rational  treatment  was  adopted.  Now,  in 
anaemia  there  is  not  found  any  degenerated  devitalized  substance; 


20  DEATH  AND  LIFE. 

the  missing  globules  have  not  relapsed  into  a  lower  life,  so  that 
their  ruins  should  constitute  a  foreign  matter ;  there  is  no  debris 
in  any  quantity  at  all  proportioned  to  the  deficient  globules  ; 
they  have  been  used  up  in  the  regular  way,  and  have  supplied 
materials  for  the  tissues,  as  they  are  moulted  off  from  day  to 
day ;  while  at  the  same  time  there  has  been  a  Avant  of  renewal, 
an  arrest  of  that  continuous  development  of  blood,  which  is 
necessary  to  complete  life. 

Pure  anosmia  has  been  spoken  of;  but,  as  might  have  been 
expected,  this  defective  supply  of  the  materials  of  growth  much 
weakens  the  vitality  of  many  of  the  manufacturing  and  excreting 
viscera:  for  their  machinery  needs  continual  repair,  as  much  as 
any  part  of  the  voluntary  apparatus.  Hence,  in  cases  of  anaemia 
Tve  often  find  that  the  liver  is  not  so  lively  as  it  should  be,  and 
some  of  the  color  it  ought  to  get  rid  of  stays  in  the  circulation, 
or  exudes  and  chronically  stains  the  skin  of  a  bilious  hue.  Or 
perhaps  the  kidneys  do  only  half  work,  and  the  urea  which  they 
ought  to  drain  ofi"  is  retained,  causing  very  serious  derangements 
of  health.  Thus  there  is  a  mixed  pathology  in  these  cases,  a 
combination  of  arrested  life  with  a  relapse  into  a  lower  life ;  the 
life  of  the  specially  afi'ected  organ  is  diminished,  and  it  leaves 
behind  in  the  system  substances  of  inferior  vitality  which  its 
proper  business  is  to  excrete  or  separate. 

Or  again,  anaemia  may  so  lower  the  creative  power  of  the 
blood,  that  instead  of  the  body  being  built  of  elastic  and  highly 
vitalized  fibrin,  it  has  to  put  up  with  a  cheesy,  brittle  substance 
called  tubercle.  This  is  just  the  sort  of  fraud  a  rascally  con- 
tractor commits  when  he  lays  your  floors  on  half-seasoned  tim- 
bers. Your  house  is  destroyed  by  dry-rot;  and  the  lungs  in 
■which  tubercle  has  been  substituted  for  healthy  connective  tissue 
gradually  soften  and  break  up.  The  most  eff'ectual  remedy  in 
both  instances  is  to  look  after  the  builders,  to  secure  the  honesty 
of  the  one  and  the  vitality  of  the  other  as  fi\r  as  possible. 

When  the  various  accidental  circumstances  of  our  daily  habits 
dispose  various  parts  of  the  body  to  even  the  few  elementary 
forms  of  disease  which  I  have  mentioned  here,  a  great  variety 
of  abnormal  phenomena  ma^'  be  produced.     Our  body  is  a  harp 


DEATH  AND  LIFE.  27 

of  so  many  strings,  that  all  sorts  of  discords  may  arise  out  of  its 
combinations.*  These  discords  have  received  much  attention 
from  minds  with  a  taste  for  order;  they  have  been  classified  into 
groups;  and  if,  unfortunately,  the  orderly  mind  was  afflicted 
with  a  theory,  sadly  have  facts  sometimes  suifered  by  the  Pro- 
crustean bed  of  a  Nosology,  into  which  they  have  been  forced. 
On  the  Avhole  the  nosologists  ['Noao'Aojoi — people  who  talk  about 
diseases)  have  been  convenient,  for  their  nomenclature  often 
helps  us  to  describe  in  one  word  what  otherwise  Avould  want  a 
parenthesis.  But  they  have  been  a  convenient  evil,  and  their 
labors  have  had  this  bad  result;  they  have  attributed  a  positive 
existence  to  that  which  in  reality  is  a  negation.  "A  Disease," 
under  their  manipulation,  instead  of  being  a  mode  in  which  life 
is  deficient,  becomes  an  actual  motive  power ;  the  giving  it  a 
generic  and  specific  name  links  it  in  our  minds  with  the  subjects 
of  a  naturalist's  studies,  and  we  get  to  clothe  it  in  individual 
characteristics,  and  to  assign  to  it  individual  actions.  The  con- 
sequences in  science  have  been  most  fatal  to  true  progress.  It 
has  had  upon  the  art  of  medicine  just  the  effect  that  would  be 
wrought  upon  Optics  by  regarding  a  shadow  as  a  material  object 
instead  of  an  absence  of  light,  upon  physics  in  general  by  ac- 
counting cold  instead  of  heat  as  the  active  agent.  The  main 
hope  for  bringing  Therapeutics  up  to  the  level  of  modern  science 
lies  in  discarding  at  once  and  forever  this  traditional  notion. 

I  am  glad  to  say  less  practical  harm  than  might  have  been 
feared  has  been  done  by  these  false  notions.  In  the  first  place 
man's  body  is  tougher  than  usually  thought,  and  will  stand  a 
great  deal  of  wrong  treatment;  and,  secondly,  experience  has 
somewhat  checked  the  bold  hand  of  a  relentless  adhesion  to 
theory.  Still,  it  can  hardly  be  doubted  that  the  increased 
chance  of  cure  under  professional  treatment  has  not  been  so 
much  as  might  have  been  expected  from  the  advance  of  general 
knowledge. 

Of  late  medical  art  as  far  as  practice  is  concerned  has  been 
turning  over  a  new  leaf;  nosologists  are  of  less  repute,  and  at 

*  "  Strange  that  a  harp  of  thousand  strings 
Should  keep  in  tune  so  long." — Watts. 


28  DEATH  AND  LIFE. 

last,  under  the  influence  of  common  sense,  attention  seems 
directed  to  the  maintenance  of  life  in  the  body  more  than  to 
the  expulsion  of  death  out  of  it.  Such  is  the  true  preaching  to 
the  sober  mind  of  the  new  modes  of  treatment  which,  without 
falling  in  with  the  dogmas  of  any  peculiar  "pa^/iy,"  have  yet 
been  silently  adopted  by  the  rational  adherents  of  each  within 
the  last  few  years.  I  may  instance  the  care  bestowed  upon  the 
section  of  alimentary  substances ;  the  use  of  water,  of  oxygen, 
of  iron,  of  animal  oils,  of  chlorine,  of  soda  in  doses  more  like  a 
food  than  a  drug,  of  lactic  and  other  organic  acids,  of  salts  of 
phosphorus  and  lime,  of  sulphur,  ammonia,  bile,  pepsin,  and 
several  other  agents  established  by  common  consent  without 
being  suggested  by  any  previous  theory  of  therapeutics,  or  tra- 
ditional rules  of  the  medical  art.  These  are  constituents  of  the 
animal  frame,  and  are  administered  and  trusted  as  to  filling  up 
an  obvious  void. 

If  experience  has  taught  us  to  reform  our  practice,  should  it 
not  teach  us  to  reform  our  theory  too?  that  so  the  partial  ad- 
vantages which  have  been  gained  might  become  universal,  and 
our  words  and  acts  might  cease  to  be  inharmonious. 

I  began  this  lecture  by  likening  the  animal  body  to  a  building 
constructed  of  perishable  materials,  which  need  continuous  re- 
newal to  maintain  the  usefulness  of  the  structure.  To  keep  up 
the  simile,  the  permanent  architect  is  the  indwelling  life,  and  he 
best  performs  his  duty,  not  by  fits  and  starts  of  work,  but  by 
ever-watchful  industry.  He  should  be  every  moment  removing 
decaying  materials  from  the  walls  and  working  machinery  to 
be  carted  away  at  convenient  periods,  and  he  should  be  every 
moment  supplying  their  place  by  fresh.  Thus  there  are  two 
departments  carried  on  simultaneously — the  "destructive"  and 
"constructive;"  and  upon  their  harmony  and  completeness  de- 
pend the  perfection  of  life  which  we  call  health.  Both  are 
necessary;  and  the  deficiency  of  either  or  both,  or  the  prepon- 
derance of  one  over  the  other  in  various  parts,  or  their  deficiency 
in  one  part  Avhile  other  parts  remain  active,  constitutes  a  de- 
ficiency of  life — a  disease. 

This  deficiency  the  physician  is  called  upon  to  remedy;   and 


DEATH  AND  LIFE.  29 

it  is  of  the  utmost  importance  to  his  usefulness  that  he  should 
recognize  that  it  is  a  deficiency,  and  act  upon  the  recognition. 
He  must  look  at  his  pharmacopoeia  with  this  thought  constantly 
present  before  him,  with  an  eye  to  the  ultimate  benefit  of  the 
patient,  to  a  goal  beyond  that  of  the  immediate  effects.  He 
should  make  his  chief  thought  how  each  of  the  reagents  em- 
ployed will  finally  touch  life;  whether  they  are  calculated  to 
add  to  or  diminish  the  vital  functions,  to  add  to  or  diminish  the 
vitalized  substance  of  which  his  patient  is  made — whether  by 
temporarily  diminishing  the  functions  or  substance  lie  may  not 
remove  an  impediment  to  their  balanced  actions,  so  as  to  lead 
to  a  final  increase — or  whether  this  artificial  diminution  of  func- 
tions or  substance  may  not  become  permanent,  and  inflict  per- 
manent injury  on  his  patient.  This  final  goal  of  life  renewal 
must  be  consciously  or  unconsciously  in  the  heart  of  the  phy- 
sician, or  in  the  heart  of  his  guides;  otherwise  I  am  sure  he 
contributes  more  to  the  ill  health  than  to  the  good  health  of 
mankind. 


LECTURE   11. 

DISEASE   AND   CURE. 

Classification  of  disease,  for  practical  purposes,  in  deficiencies  of 
growtli  and  deficiencies  of  7noulting — (I)  Deficiencies  of  growth 
from  ChossaCs  observations — Analogous  natural  states  in  dis- 
ease— (II)  Deficiencies  of  moulting,  true  and  apparent — Mixed 
lesio7is — Natural  cure  and  artificial  cure — Cure  origi^iated  by 
the  healthy  parts  of  the  body — Classification  of  means  of  cure — 
Constructives — Destructives — Arresters  of  construction — Ar- 
resters of  destruction. 

{Introductory  Clinical  Lecture  at  St.  Mary  s  Hospital,  delivered 
October  5,  1863.) 

You  are  now  entering  on  the  most  serious  part  of  jour  student 
life;  you  come  to  the  hospital  wards  to  study  Disease — that  fitful 
twilight  coming  between  the  glad  radiance  of  life  we  call  health, 
and  death,  the  drear  darkness  of  its  departure.  You  see  the 
gloom  sometimes  irrevocably  deepen,  more  often  melt  back  again 
into  the  beams  of  returning  day ;  and  you  would  fain  learn  how 
to  promote  this  joyful  event  which  we  hail  as  Cure.  To  minister 
to  it  is  to  be  the  business  of  your  lives;  and  therefore  time  can- 
not be  wasted  in  first  thoughtfully  considering  what  it  is. 

Healthy  life  consists  in  a  continuous  and  equally  balanced 
repetition  of  the  two  necessary  parts  of  the  renewal  of  the  body, 
constructive  and  destructive  assimilation,  in  other  words,  "grow- 
ing and  moulting."  The  essential  nature  of  disease,  that  which 
makes  it  disease,  is  a  deficiency  of  health,  a  deficiency  of  either 
construction  or  destruction  in  one  or  more  points.  The  cure  of 
disease,  natural  or  artificial,  consists  in  a  new  birth  or  renewal 
of  the  deficient  life. 


DISEASE  AND  CURE.  31 

The  practitioner,  to  Avliose  mind  the  cure  should  be  the  ever 
present  object,  will  therefore  do  well  to  classify  as  far  as  he  can 
all  morbid  phenomena  on  this  principle;  for  on  this  principle 
will  be  based  his  most  successful  practice. 

Do  not  suppose  that  I  am  here  condemning  or  proposing  to 
reform  the  existing  nosology  of  statisticians.  Every  classifica- 
tion must  be  constructed  for  a  specific  purpose ;  it  can  be  com- 
plete, and  its  classes  be  prevented  from  overlapping,  only  by 
that  one  specific  purpose  being  adhered  to.  For  his  own  specific 
purpose  the  hospital  porter  divides  diseases  into  those  of  males 
and  those  of  females,  and  subdivides  these  again  into  medical 
and  surgical.  An  officer  of  health  classes  them  as  Epidemic, 
Endemic,  Enthetic,  Sporadic,  &c. ;  a  philanthropist  according 
to  their  causation  by  various  occupations,  as  diseases  of  painters, 
clergymen,  coppersmiths,  chimneysweeps,  &c.  An  anatomist 
arranges  them  "a  capite  a  calcem,"  (as  Morgagni  says  he  does), 
according  to  the  part  affected.  Some  pathologists  aim  high  at 
a  kind  of  natural  system,  and  class  together  those  phenomena 
whose  essential  nature,  whose  morbid  processes  seem  alike;  for 
the  diseases  are  primarily  divided  into  Zymotic,  Tubercular, 
Cancerous,  Hsemorrhagic,  Catarrhal,  Arthritic,  &c.  The  Re- 
gistrar-General, who  has  to  provide  a  single  nomenclature  for  a 
great  variety  of  temporary  purposes,  and  suited  to  a  great  variety 
of  pinds,  wisely  contents  himself  Avith  a  very  imperfect  and  illo- 
gical classification  as  a  gradual  stepping-stone  to  a  better.  For 
nomenclature  the  best  working  classification  is  the  one  which 
contains  the  greatest  quantity  of  well-known  appellations,  and 
for  common  purposes  that  which  is  most  common. 

But  this  classification  is  most  faulty  when  applied  to  aid  us  in 
therapeutics.  To  take  it  as  our  only  classification  is  to  introduce 
an  arbitrary  method  into  the  treatment  of  disease  which  cannot 
but  impede  all  true  progress,  not  only  in  the  mind  of  the  indi- 
vidual practitioner,  but  of  the  art  itself.*     However,   our  pos- 

*  The  dauger  is  clearly  pointed  out  in  the  "London  Medical  Review"  for 
March,  1863.  "The  dictionaries  and  encyclopasdias  of  medicine,  useful  as  store- 
houses of  facts,  have  done  much  to  perpetuate  this  error  with  the  unthinking 
portion  of  our  fraternity.     With  many  even  at  the  present  day  a  sick  person  is 

\ 


32  DISEASE  AND  CURE. 

session  of  it  and  use  of  it  for  its  intended  purposes,  does  not 
preclude  special  classifications  for  special  objects;  and,  indeed, 
the  more  ways  a  man  has  of  classifying  a  subject  the  more  he 
Avill  know  about  it,  and  the  more  ready  he  will  be  with  his 
knowledge. 

I  shall,  therefore,  not  hesitate  to  recommend  for  therapeutical 
purposes  an  attempt  to  classify  morbid  phenomena  after  a  fashion 
Avhich  I  confess  would  be  inconvenient,  if  not  impossible,  to  ap- 
ply to  them  for  other  objects. 

Life  we  know  to  be  a  state  of  unending  change;  and  this 
change  is  double — constructive  of  the  body  from  foreign  ma- 
terials, and  destructive  of  it  into  inorganic  elements.  The  phy- 
sician, then,  in  his  ministry  of  the  living  body,  has  to  be  always 
dealing  with  construction  or  destruction,  or  both  together;  and 
it  must  make  a  great  deal  of  difference  for  him  to  be  able  to 
recognize  which  part  of  life  he  is  dealing  with;  because  the  in- 
struments he  employs  to  modify  these  opposite  parts  of  life  must 
be  in  some  Avay  of  opposite  natures. 

Therefore  I  cannot  but  think  we  should  be  contributing  very 
much  to  our  practical  usefulness,  if  we  tried  habitually  to  divide 
morbid  phenomena  into  (1)  Deficiencies  of  nutrition  or  of  con- 
structive form  building,  and  (2)  Deficiencies  of  moulting  or  of 
form-destruction. 

We  should  thus  have  ready  to  hand  a  decisive  spur  to  a  defi- 
nite course  of  treatment  in  all  cases;  whatever  empirical  or  tra- 
ditional means  we  adopt  would  be  under  the  control  of  a  final 
principle,  and  we  should  feel  quite  sure  that  we  were  at  all  events 
aiming  at  a  rational  end.* 

regarded  as  a  sort  of  living  conundrum  to  which  there  is  but  one  correct  solu- 
tion— a  Greek  or  Latin  word  indicating  his  disease.  When  this  is  guessed,  the 
word  is  as  it  were  'looked  out'  in  a  sort  of  mental  dictionary  where  the  prac- 
titioner finds  against  it  appropriate  treatment  according  to  his  lights.  The 
arbitrary  practice  thus  induced  strongly  resembles  the  child's  idea  of  coloring  a 
printed  sketch — this  is  a  tree,  and  therefore  it  must  be  green;  sky,  blue  of 
course;  water,  ditto;  glass,  ditto;  a  road,  burnt  sienna."  There  are  some  ex- 
cellent remarks  on  classification  in  the  preface  to  Dr.  Reynolds'  volume  on 
Epilepsy. 

*  In  my  systematic  lectures  on  the  practice  of  medicine  I  have  been  used  for 
the  last  ten  years  to  adopt  a  classification  similar  to  this  in  the  first  part  of  the 


DISEASE  AND  CURE. 


33 


But  is  it  possible  to  make  this  division?  Much  more  possible 
than  appears  at  first  glance,  if  we  will  first  consent  to  clear  our 
minds  of  nosological  prejudices  begotten  of  old  theories,  and 
come  to  the  task  fresh  and  unfettered,  ready  to  accept  all  the 
conclusions  which  independent  observation  may  supply.  I  will 
point  out  a  few  of  the  more  obvious  sources  of  knowledge  which 
may  help  us  to  the  required  end. 


First,  for  deficiencies  of  nutrition  or  form-building. 

The  morbid  phenomena  capable  of  being  classed  under  this 
head  are  doubtless  to  be  found  most  purely  displayed  by  starva- 
tion and  loss  of  blood  in  otherwise  healthy  bodies.  The  labors 
of  M.  Chossat  and  Dr.  Marshall  Hall  have  almost  exhausted 
these  subjects,  and  are  easily  accessible  to  all. 

We  find  fully  established  by  M.  Chossat's*  rigorous  experi- 

course,  which  includes  general  pathology^  and  consequently  the  principles  of 
therapeutics. 

f  Of  ivhole  of  blood — Haemorrhage, 

rr         ^  7         .-.  transudation. 

I  Loss  of  normal  consM' 

I       „,„,,  i  Of  part    of    blood— Serous    dis- 

charges,    sero-fibrinous     ditto, 
antemia,  albuminuria,  &c. 

I    ,,  ,       ,    ,.         ^  f  Ura?mia,  asphyxia,  jaundice,  lithic 

-J  Abnormal   retention  of  \  i      t-  j       :  j  t 

.[       acid  and  oxalic  acid  diathesis, 

excretions i 

I      &c. 


uents 


Morbid  Changes 
IN  Fluids    .  .  . 


Morbid  Changes 
in  Solids    .  .  . 


Foreign  additions 


Arrests  of  development 
into  normal  tissue  .  . 


f  1.  Common  poisons. 
I  2.  Morbid  poisons. 
(  {I.)  Of  blastemas — Mucus,  pus,  tu- 
bercle. 
(2.)  Of  cartilage-cells — Cancer  and 

some  other  tumors. 
(3.)  Of   white   fibrous  tissue — Cir- 
rhosis, false  membranes,  gra- 
nular    kidneys,     contracting 
[^  scars,  &c. 

Retrogression  to  the  formation  of  less  vital  tissue,  or  degenera- 
tion,   fibrinous,    waxy,    fatty, 
chalky,  or  mineral,  &c. 
Foreign  additions  ....     Parasites. 
In  the  second  part  of  the  course  these  changes  are  arranged  anatomically. 
*  "  Recherches  experimenitales  sur  rinanition."    Paris,  1843. 


34  DISEASE  AND  CURE. 

merits  on  healthy  animals  certain  phenomena  as  resulting  from 
the  deprivation  of  food,  and  therefore  as  resulting  from  the 
arrest  of  continuous  growth  by  the  want  of  its  material.  They 
are  as  evidently  phenomena  of  innutrition  as  the  ruin  of  an  un- 
repaired building  is  a  phenomenon  of  the  want  of  bricks. 
Prominent  among  these  phenomena  we  find  : 

1.  Collections  of  fluid  in  the  serous  sacs  (p.  73). 

2.  CEdema  of  the  extremities  (p.  82). 

3.  Softening  and  destruction  of  the  mucous  membranes  (p.  85). 

4.  Thickening  of  the  epithelium  elsewhere  (p.  86). 

5.  Blackening  of  the  viscera,  especially  the  liver ;  and  redden- 
ing (?  with  hsematine)  of  the  secretions,  at  least  of  the  bile  (p. 
74).  Sometimes  the  substitution  of  brownish-red  congestion  for 
the  black  (p.  74). 

6.  Bluish,  livid,  yellow,  whitish  and  reddish  stains  during  life 
in  the  transparent  parts  of  the  skin  (p.  73). 

7.  Loss  of  weight,  producing  death  when  it  amounts  to  as 
much  as  ^^r  of  the  normal  weight  (p.  21). 

8.  Hectic  fever.  That  is  to  say,  very  marked  oscillations  of 
the  diurnal  variation  of  temperature  (p.  123). 

9.  A  continuous  decrease  in  the  power  of  the  body  to  resist 
cold  (p.  132). 

10.  At  first  a  scanty  excretion  of  dry,  bilious,  grass-green 
faeces,  and  afterward  diarrhoea  of  liquid  saline  matter  (p.  151). 

11.  Excitability  of  involuntary  muscular  fibers  by  stimuli. 
Even  after  death  the  auricles  of  the  heart  of  starved  animals 
retained  for  an  unwonted  length  of  time  their  contractility  on 
being  touched  (p.  150). 

12.  Convulsions,  similar  to  those  in  death  by  haemorrhage  (p. 
187).     The  convulsions  were  often  episthotonic. 

13.  In  comparing  the  losses  of  substance  in  the  different 
tissues  of  starved  animals,  the  nervous  system  appeared  to  have 
suffered  least,  and  indeed  retained  nearly  its  full  weight  after 
death.  This  and  the  former  observations  seem  to  point  it  out 
as  the  true  ultimum  mo7nens  in  such  circumstances  (p.  91). 


DISEASE  AND  CURE.  35 

Here  are  a  collection  of  phenomena  which  we  are  daily  wit- 
nessing in  our  patients,  modified  of  course  by  the  fact  that  in 
them  usually  the  defect  in  the  supply  of  materials  of  growth  is 
but  partial.  Shall  we  be  wrong  in  attributing  such  phenomena 
to  innutrition  ?  Still  more,  shall  we  be  wrong  in  treating  them 
as  innutrition? 

I  will  allude  to  a  few  of  the  cases  in  which  you  see  these 
phenomena  as  the  result  of  the  imperfect  vitality  we  call  disease, 
referring  by  a  corresponding  numeral  to  similar  phenomena  in- 
tentionally produced  by  starvation  in  M.  Chossat's  experiments. 

1.  The  conventional  term  "effusion"  applied  to  dropsies  of 
the  serous  sacs  is  misleading  to  students.  They  are  apt  to  fancy 
it  an  active  process,  in  which  the  inconvenience  arises  from  the 
itiembrane  "effusing"  too  much  fluid,  and  their  minds  are  im- 
mediately directed  to  the  necessity  of  checking  this  imaginary 
activity;  whereas  in  reality  the  membrane  need  not  pour  out 
more  than  it  does  in  health,  nay,  it  may  pour  out  much  less  than 
it  does  in  health,  and  yet  dropsy  very  rapidly  take  place  by  the 
arrest  of  absorption ;  and  it  is  from  this  arrest  of  absorption  in 
consequence  of  generally  diminished  vitality  that  collections  (as 
they  should  be  called  rather  than  "effusions")  of  fluid  take  place 
in  the  pleural,  peritoneal,  and  pericardial  sacs.*  You  find  them 
in  anaemia,  hydrsemia,  ureemia,  leucocythsemia,  and  other  con- 
ditions unnamed  as  yet,f  where  the  blood  in  the  diminished 
proportion  of  its  chief  vital  constituent  of  red  globules  typically 
represents  in  common  parlance  the  generally  diminished  vitality 
of  the  whole  body.  From  the  diminished  consistence  of  the  cir- 
culating fluid  the  eudosmose  inwards  of  liquids,  that  is,  absorp- 
tion, is  diminished  accm'ding  to  the  well  known  law  of  trans- 
fusion. 

Again,  these  collections  of  fluid  arise  wherever  the  circulation 
is  arrested  by  mechanical  impediments,  as  in  cardiac  or  hepatic 
disease  for  example.  Here  comes  into  play  another  law  of 
diosmose,  namely,  that  in  the  case  of  a  moving  liquid  it  takes 
place  in  a  direct  ratio  to  the  quickness  of  the  motion.    The  more 

*  See  Lecture  XVII  of  this  volume,  on  hydrothorax. 
f  Carent  quia  vate  sacro. 


36  DISEASE  AND  CURE. 

the  circulation  is  slackened  the  more  obstinate  the  dropsy  is,  and 
increasing  its  living  force  and  freedom  cures  the  patient. 

If  we  cannot  detect  any  of  tliese  explicable  organic  modes  of 
dropsy's  oiigin,  it  is  still  surely  philosophical  to  conclude  that  a 
similar  agency,  a  similar  deficiency  of  life  is  acting  throughout.* 

2.  The  remarks  I  have  made  apply  equally  well  to  anasarca, 
which  is  a  collection  of  fluid  in  the  small  sacs  of  the  areolar 
tissue,  instead  of  the  large  serous  sacs. 

3  and  4.  It  is  most  interesting  to  find  morbid  states  of  the 
mucous  membrane  characterized  by  softening  and  destruction, 
and  also  by  thickening,  produced  as  the  direct  result  of  inanition. 
How  apt  we  have  been  to  look  upon  this  changed  form  of  vitality 
and  this  accumulation  of  semi-vitalized  substance  as  evidence  of 
activity  !  h(>w  apt  we  have  been  to  reduce  the  vitalitj'  in  our  aims 
at  cure.  I  need  hardly  allude  to  ulcerations  and  rugged  con- 
ditions of  the  stomach,  of  the  throat,  of  the  vagina,  and  neck  of 
the  womb,  which  have  been  treated  to  their  great  injury  by  de- 
pressing medicines. 

5.  We  are  very  much  inclined  from  ancient  prejudices  to  take 
congestion  for  a  proof  of  active  life,  and  the  red,  black,  or  other 
dark-coloured  relics  of  congestion,  as  post-mortal  evidences  of 
activity  in  the  organ  so  discolored.  It  appears  to  indicate  the 
direct  contrary. 

6.  So  also  with  livid  and  reddish  discolorations  of  the  living 
skin.  How  often  do  you  hear  it  remarked  that  a  red,  bloated- 
faced  man  wants  "bringing  down,"  when,  in  fact,  what  is  re- 
quired is  a  more  vitalized  blood,  and  a  more  vigorous  action  of 
the  heart  and  arteries.  How  often  is  a  patient  drenched  with 
mercurials  and  purgatives  because  he  is  "black  under  the  eyes," 
when  tonics  and  better  diet  are  the  true  specifics.  Blueness  and 
blackness  of  the  sclerotic,  again,  is  a  safe  indication  for  tonics, 
and  the  finger-nails  may  also  be  used  as  a  guide  to  the  same 
treatment. 

7.  The  regularity  with  which  death  results  on  the  loss  of  a 
certain  amount  of  weight  should  lead  us  to  make  more  use  than 
we  do  of  the  balance,  that  easily  applied  aid  to  diagnosis,  prog- 


DISEASE  AND  CURE.  37 

nosis,  and  treatment.     It  is  a  direct  measure  of  the  success  of 
our  medicines,  or  of  the  progress  of  disease. 

8.  Hectic  fever  is  an  obscure  subject.  But  I  think  some  ap- 
proach to  an  elucidation  of  it  may  be  made  from  the  direction 

■  of  those  singuhir  nycthemeral  osciUations  of  temperature  which 
take  phice  in  health.  In  full  vigor,  the  normal  production  of 
animal  heat  rises  gradually  up  to  its  maximum  at  noon,  and  falls 
to  its  minimum  at  midnight.  In  health  this  variation  is  slight, 
but  in  the  simple  debility  produced  by  deficient  food  it  is  more 
than  quadrupled.  In  M.  Chossat's  experiments  it  rose  from 
0-7-1:°  to  o*28°.  The  extreme  of  heat  was  so  much  more,  and 
the  extreme  of  cold  was  so  much  more  than  in  health  ;  and  not 
onl}''  was  this  change  observed,  but  also  that  the  periods  of  the 
accession  and  diminution  became  irregular,  and  were  not  governed 
by  the  diurnal  time.  Do  not  these  observations  distinctly  associate 
periodic  fevers,  and  through  them  perhaps  the  periodicities  of 
disease,  with  direct  debility? 

9.  The  liability  to  be  injuriously  aifected  by  external  .agents, 
especially  by  cold,  is  a  sure  proof  of  deficient  vitality.  This  is 
not  always  accompanied  by  sensitiveness  to  the  changed  tempera- 
ture, but  is  made  evident  by  catarrhs,  bilious  attacks,  local  in- 
flammations, congestions,  &c.,  and  is  often  popularly  rated  as 
characteristic  of  "an  inflammatory  subject." 

10.  M.  Chossat's  observations  of  the  alvine  evacuations  are 
very  valuable.  Let  us  never  forget  that  not  only  constipation, 
but  also  diarrhoea,  and  an  exceedingly  foul  condition  of  the  ex- 
cretions, may,  and  in  fact  generally  do,  arise  from  mere  inanition. 
This  is  an  important  lesson  for  routine  adherents  of  blue  pill  and 
black  dose. 

The  commonest  instance  we  have  of  fetid  evacuations  from 
inanition  is  that  of  unfortunate  babies  who  have  been  starved 
by  hand-feeding,  or  by  the  imperfect  condition  of  their  mother's 
milk.  Perhaps  mercury  may  make  the  stools  less  disagreeable 
for  a  time,  for  it  throws  into  the  bowels  a  quantity  of  bile,  which 
prevents  their  decomposition,  but  that  is  done  at  the  expense 
of  the  poor  infant's  body,  and  must  contribute  to  further  the 
debility. 


38  DISEASE  AND  CURE. 

11.  The  weaker  the  life  the  quicker  the  heart  beats,  and  the 
readier  it  is  excited.  This  phenomenon  is  particularly  well 
marked  in  zymotic  fevers,  Avhere  the  rapidity  of  the  pulse  is  a 
good  guide  to  the  degree  in  which  the  poison  of  the  fever  has 
affected  the  system,  and  what  force  the  system  has  to  bear  u^i 
against  the  poison.  In  pneumonia  too,  the  rapidity  of  the  pulse 
is  usually  in  a  direct  ratio  to  the  danger,  and  to  the  necessity 
for  opiates  and  stimulants.  In  pulmonary  consumption,  starving, 
depressants,  expectorants,  salines,  and  all  that  is  usually  classed 
as  antiphlogistic  treatment,  makes  the  pulse  quicker  and  quicker, 
and  nothing  reduces  it  so  steadily  as  oil  and  other  restoratives. 

12.  The  knowledge  that  convulsion  arises  when  there  is  a 
deficient  supply  of  blood  to  the  brain,  has  been  a  long  time  in 
forcing  upon  the  profession  the  conviction  that  it  is  a  disease  of 
inanition.  Perhaps  the  impediment  has  been  the  finding  in  post- 
mortem examinations  black  blood,  rendering  abnormally  con- 
spicuous the  smaller  vessels  and  capillaries,  when,  in  certain 
diseases,  convulsions  have  preceded  death.  The  blood  is  too 
visible,  and  so  the  fallacy  has  been  jumped  to  that  it  is  too 
abundant.  The  real  fact  is,  that  it  is  too  stagnant,  that  it  is 
too  arterial,  too  little  renewed.  Perhaps  the  great  show  that 
convulsions  make,  the  natural  awe  which  they  excite  among  the 
bystanders,  and  the  active  help  they  seem  to  call  for,  impress 
us  with  an  idea  of  activity  of  life  in  the  sufferer.  Chorea, 
epilepsy,  teething  fits,  convulsive  apoplexy,  delirium  tremens, 
hysteria,  and  some  forms  of  mania,  are  familiar  instances.  But 
in  all  of  these  every  experimental  improvement  made  from  year 
to  year  in  the  treatment  is  in  the  direction  of  replacing  lost 
nervous  power,  not  of  restraining  its  excess. 

13.  The  difficulty  which  the  nervous  tissue  exhibits  in  parting 
with  its  substance  by  vital  decay,  explains  the  difficulty  of  its 
renewal.  There  are  no  patients  so  slow  in  recovering  health 
as  those  whose  nervous  system  is  exhausted.  They  are  months 
or  years  in  getting  ill  perhaps,  and  they  are  months  or  years 
in  getting  well.  Let  our  recollection  of  the  slow  growth  of  this 
tissue  comfort  us  under  such  circumstances.  The  time  and  com- 
pulsory idleness  needful  for  its  restoration  make  it  the  most  ex- 


DISEASE  AND  CURE.  39 

pensive  of  tissues  to  get  worn  out,  and  rightly  enough  its  higher 
manifestations  are  most  highly  paid  for. 

Among  diseases  of  deficient  construction  may  also  be  included 
the  tissue  diseases  of  degeneration,  where  instead  of  highly 
vitalized  elastic  material  a  brittle,  or  a  soft,  or  a  formless  mass 
is  deposited.  It  is  alive,  but  imperfectly  alive,  easily  dies,  and 
is  useless  while  it  lives.     Tubercle  is  a  substance  of  this  sort. 

It  appears  strange  at  first  glance  that  some  organic  matters 
which  are  referable  to  this  class  should  carry  out  of  the  sj^stem 
with  them  a  spark  of  half  independent  vitality.  Cancer,  for 
example,  multiplies  itself  conspicuously,  and  so  does  pus  in  a 
more  hidden  manner,  so  long  as  they  can  get  their  food  from 
the  body.  But  this  multiplication  is  the  lowest  (one  might  say 
the  most  diluted)  form  of  life,  and  certainly  indicates  no  re- 
dundancy in  the  parent  system. 

M.  Chossat  remarks,  "Bichat  and  the  physiologists  who  have 
been  occupied  on  the  same  subject  before  and  after  him  have 
thrown  the  greatest  light  upon  the  causes  of  death,  by  classify- 
ing them  according  to  the  functions  which  help  to  bring  them 
on.  In  dividing  death  into  death  by  the  brain,  death  by  the 
lungs,  and  death  by  the  heart,  they  run  through  the  series  of 
vital  functions,  and  suppose  that  they  have  thus  exhausted  the 
subject.  However,  on  coming  to  facts,  it  is  certain  that  we 
thus  explain  but  a  small  number  of  the  cases  of  death,  and  that 
the  great  majority  of  those  brought  under  our  observation  escape 
this  classification.  This  is  so  even  in  the  cases  Avhich  seem  easiest 
to  lend  themselves  to  this  division.  In  pulmonary  consumption, 
for  instance,  who  can  say  that  usually  death  supervenes  by 
asphyxia  ?  for  the  lung  on  the  day  of  decease  is  not,  as  a  rule, 
more  disorganized  than  it  was  the  day  before;  and  yet  the  day 
before  it  sufficed  for  the  aeration  of  the  blood.  On  the  other 
hand,  who  has  not  witnessed  autopsies  in  a  number  of  febrile 
maladies,  in  which  there  is  no  morbid  change  found,  except 
lesions,  often  very  insignificant,  in  the  intestinal  canal  ?  One 
cannot,  without  doing  violence  to  the  judgment,  consider  these 
as  sufficient  to  account  for  the  death.  The  fact  is,  the  classifi- 
cation of  Bichat  does  not  explain  all,  and  to  the  three  modes  of 


40  DISEASE  AND  CURE. 

death  which  he  points  out  we  must  needs  add  at  least  a  fourth — 
death  by  the  digestive  apparatus,  or  inanition."* 

M.  Chossat  is  quite  right;  indeed  he  rather  underrates  his 
case:  very  much  more  than  half  the  patients  we  lose  die  from 
imperfect  nutrition,  and  very  much  more  than  half  of  those  who 
recover  gain  that  end  by  chanced  or  designed  restoration  of  their 
digestive  functions. 

Exactly  the  same  means  that  prevent  death,  prevent  or  cure 
disease.  This  may  seem  a  platitude,  but-  it  is  a  very  important 
one,  and  must  not  be  allowed  to  "lie  bed-ridden  in  the  dormitory 
of  the  soul"  because  it  is  so  true.  All  are  ready  enough  to  admit 
that  when  a  patient  is  in  danger,  the  first  thing  to  be  done  is  to 
keep  him  alive.  Act  in  the  same  way  when  he  is  not  in  danger; 
cure  him  by  sustaining  the  partially  or  locally  failing  life;  post- 
pone partial  death,  as  you  would  postpone  total  death. 

(II.) 

Disease  of  destruction,  or  deficient  moulting,  commences  when 
the  functions  whose  business  it  is  to  remove  efiete  products  from 
the  tissues  are  inefficient.  I  say  "  functions"  designedly  instead 
of  organs,  in  order  to  include  the  whole  process  from  the  period 
when  the  tissue  becomes  eifete  to  the  expulsion  of  the  products 
of  its  decay  from  the  body.  For  in  whatever  part  of  the  pro- 
cess a  check  takes  place,  the  result  on  the  whole  health  is  iden- 
tical, and  the  principles,  though  not  perhaps  all  the  details,  of 
the  treatment  must  be  the  same.  And  in  whatever  part  a  check 
takes  place,  the  main  injury  is  the  stoppage  of  vital  metamor- 
phosis at  its  origin. 

This  is  the  case  even  in  mere  mechanical  obstruction.  Take 
for  instance  the  impaction  of  a  gall-stone  in  the  common  duct; 
first  the  intestines  are  in  want  of  bile — that  is  a  deficiency  they 
can  easily  bear ;  then  the  gall-bladder  and  the  ducts  get  dis- 
tended— which  does  not  interfere  very  much  with  the  patient's 
comfort ;  but  the  real  serious  injury  is  the  non-removal  frqm 
the  blood  and  tissues  of  what  forms  the  biliary  secretion.  And 
the  injury  is  of  exactly  the  same  nature,  whether  the  jaundice 

*  Page  194. 


DISEASE  AND  CURE.  41 

arises  in  the  mechanical  way  alluded  to,  or  whether  it  arises  in 
the  ultimate  tissues  themselves,  as  jaundice  from  mental  impres- 
sion for  example. 

It  might  seem  at  first  sight  as  if  diseases  of  deficient  moulting 
were  exceedingly  easy  to  detect,  and  to  reduce  to  classification. 
We  are  in  a  position  to  measure  accurately  the  quantity  and 
quality  of  the  most  important  excretions,  and  can  approximate 
to  a  knowledge  of  those  not  so  readily  reckoned.  We  can  know 
hy  experiment  the  daily  excretion  of  urea,  phosphoric  acid, 
sulphuric  acid,  and  water  by  the  kidneys ;  of  carbonic  acid  by 
the  lungs  ;  of  faeces  by  the  bowels  ;  of  water  and  salts  by  the 
skin,  and  we  can  find  out  with  a  fair  approach  to  accuracy  when 
these  are  diminished.  But  in  the  great  majority  of  cases  this 
diminution  is  in  reality  the  consequence  of  deficient  supply  ; 
vital  decay  does  not  remove  the  tissues,  because  there  is  no  new 
material  to  take  their  place.  To  call  these  cases  instances  of 
deficient  moulting  is  a  misappropriation  of  terms,  and  to  treat 
them  as  such  most  pernicious. 

The  most  familiar  example  is  the  amenorrhoea  of  weakly 
females.  To  what  purpose  are  emmenagogues  ?  Why  should  we 
wish  to  force  the  ovaries  or  uterus  to  bleed,  when  the  reason  why 
they  do  not  bleed  is  that  there  is  not  enough  blood  formed  ?  The 
custom  of  administering  purgatives,  whenever  the  bowels  are  not 
open  so  often  as  those  of  robust  persons,  is  another  too  familiar 
instance  of  mistaking  the  true  nature  of  the  deficiency. 

The  only  diseases  we  can  safely  refer  to  the  class  now  con- 
sidered are  those  where  the  effete  product  is  obviously  retained 
in  excess  in  the  system,  and  where  the  impediment  to  its  ex- 
cretion is  usually  the  imperfect  action  of  the  secerning  organ, 
such  as  urj»mia  or  the  excess  of  urea  in  the  blood  from  degene- 
rated  kidneys,  asphyxia  or  retention  of  carbonic  acid  from  non- 
aeration,  jaundice  from  mechanical  impediment,  or  incomplete 
development  of  hepatic  cells,  and  perhaps  certain  cases  of  the 
lithic  acid  diathesis. 

In  most  of  the  patients  we  have  to  do  with,  both  classes  of 
morbid  phenomena  are  united ;  there  is  a  general  deficiency  of 
life,  and  both  nutrition  and  destruction  are  below  par,  often  in 


42  DISEASE  AND  CURE. 

equal,  more  often  in  unequal  proportions.  The  instance  T  have 
just  given  of  urseniia  is  in  point ;  one  marked  change  in  the 
blood  is  the  retention  in  it  of  urea,  the  product  of  destructive 
metamorphosis,  which  acts  as  a  poison  ;  but  another  change, 
certainly  more  Avorthy  of  consideration  as  being  more  under  our 
control,  is  the  absence  of  red  blood-discs  by  reason  of  defective 
nutrition.  Hence  we  have  mixed  phenomena  from  the  union  of 
the  two. 

I  would  say  incidentally  that  there  are  few  cases  in  which  the 
defective  nutrition  is  not  at  the  same  time  the  most  important  in 
a  pathological  sense  as  explaining  natural  phenomena,  and  at 
the  same  time  the  most  important  in  a  therapeutical  sense,  as 
being  the  most  easily  compensated. 

Be  it  remarked  also  that  mixed  phenomena,  requiring  mixed 
treatment,  arise  sometimes  from  the  deficiency  in  one  part  of 
the  chain  of  vital  acts  overthrowing  the  balance  of  functions 
found  in  health.  An  apparent  excess  of  certain  functions  or 
constituents  arises  from  the  absence  of  those  which  normally  are 
in  correspondence  with  them.  Thus  Dr.  Prout,  to  whom  the 
pathology  of  urinary  diseases  owes  so  much,  speaks  of  a  "phos- 
phatic  diathesis,"  and  we  not  uncommonly  hear  medical  men 
speak  of  "phosphatic  urine"  as  if  the  ailment  were  an  excess 
of  the  salts  of  phosphorus ;  although  in  reality  in  such  cases 
those  constituents  of  the  excretion  are  usually  less  copious  than 
in  health,  and  are  deposited  only  from  deficiency  of  the  acid 
which  should  hold  them  in  solution. 


The  object  of  medical  treatment  is  cure.  The  end  of  the 
physician's  labor  and  care  is  accomplished  by  the  patient  get- 
ting well.  What  is  this  cure  of  getting  well  ?  It  is  a  restora- 
tion of  the  disordered  body  to  its  natural  state  of  ease  or  health. 

This  restoration  we  often  see  come  to  pass  independent  of  any 
interference  from  without,  by  what  is  allegorically  called  an 
"  efl'ort  of  nature."  Wounds  heal,  diseases  cease,  in  men  and 
animals  wdio  have  none  to  help  them.  The  event  comes  about, 
not  in  consequence  of  the  driving  out  of  any  materies  morhi,  but 


DISEASE  AND  CURE.  43 

on  the  resumption  of  their  normal  functions  by  the  diseased 
organs :  the  full  vital  force  regains  its  influence  in  them,  and 
they  recover.  The  social  disease  of  "a  strike"  is  cured  by  the 
hands  going  on  work  again. 

Now  diseased  organs  must  necessarily  have  less  power  in 
them  than  healthy  ones;  and  it  is  obvious  therefore  that  the 
curative  vitality  must  mainly  be  due  to,  and  proceed  from,  those 
which  remain  healthy.  It  is  to  their  having  some  sound  action 
to  spare  that  the  sick  man  owes  his  recovery.  The  vital  force 
at  the  same  time  removes  the  retained  products  from  the  tissues, 
and  replaces  them  by  new  material.  This  is  the  true  teaching 
of  nature's  cure. 

Cures  by  art  are  effected  in  exactly  the  same  way.  Every 
artificial  appliance  which  does  not  aid  this  one  only  mode  of  re- 
covery is  an  impediment  to  it,  or  simply  a  nullity.  A  drug  m 
itself  effects  nothing  by  its  mere  chemical  or  neutralizing  influ- 
ence ;  it  is  the  vital  power  which  this  drug  calls  forth,  or  frees 
from  a  burden,  that  is  the  true  healer.  Quinine,  for  instance, 
will  not  neutralize  malarious  poison ;  Peruvian  marshes  are  not 
less  deadly  for  cinchona  trees  falling  into  them  ;  but  the  drug's 
vital  action  on  that  which  remains  healthy  of  the  body  cuts 
short  the  fever  which  is  the  consequence  of  that  malarious  poison. 
The  action  of  a  remedy  by  which  a  sick  body  becomes  sound 
must  be  looked  upon  as  a  vital  act  of  the  body  itself  and  not  a 
simple  act,  but  a  series  of  vital  acts,  which  grow  out  of  one 
another  in  regular  succession  as  the  branches  grow  from  a  tree. 
They  are  not  dependent  upon  the  continuous  presence  of  the 
remedy,  but  persist  long  after  it  is  removed  from  the  system, 
just  as  a  railway  train  goes  on  "  of  itself"  (as  we  conventionally 
say)  when  disconnected  from  the  locomotive.  The  true  art  of 
healing  consists  in  the  establishment  of  vital  acts  tending  towards 
the  renewal  of  the  body,  towards  a  new  birth  of  diseased  tissue, 
and  in  the  encouragement  and  aiding  of  those  vital  acts  after  the 
removal  of  their  original  excitant. 

Since  there  are  two  parts  in  the  chain  of  life,  "  construction" 
and  "destruction,"  and  since  external  agencies  may  act  upon 
these  in  two  ways  by  increasing  them  or  diminishing  them,  a 


44  DISEASE  AND  CURE. 

primary    fourfold    classification    of    curative    agents    naturally 
arises;  and  this  will  be  the  most  handy  classification  for  a  prac- 
tical man. 
We  have — 

(1.)   CoNSTRTJCTiVES  (^laroTpofiKa)  OT  aids  to  formative  nutrition. 
(2.)  Destructives   ['icToivrtKa)  or  augraenters  of  destructive 
assimilation. 

(3.)  Arresters  or  construction  {pioihafihTiKa). 
(4.)  Arresters  of  destruction  {fiiocpviaKTiKa). 

Among  Constructives  we  have  the  following  classes: — 

1st.  The  materials  of  which  the  body  is  built  up :  albumen, 
fibrine,  gelatine,  fat,  oil,  water,  iron,  lime,  phosphatic  salts,  soda, 
ammonia,  sulphur,  oxygen,  ^c,  which  are  generally  taken  in  the 
form  of  food. 

2nd.  Medicines  which  appear  to  act  by  replacing  necessary 
constituents  of  the  body. — This  is  as  yet  a  very  dimly  understood 
class ;  but  we  may  hope  something  from  the  progress  of  physio- 
logical chemistry  to  explain  the  action  of  sundry  medicines,  which 
we  cannot  doubt  will  be  proved  restoratives,  though  we  cannot 
at  present  see  by  what  steps.  Quina  and  other  vegetable  alka- 
loids may  be  taken  as  an  example,  whose  cure  of  ague  may  be 
best  explained  by  supposing  them  to  replace  some  constituents 
of  the  body  destroyed  by  malaria. 

3rd.  Digestive  solvents. —  Water,  which  must  be  in  excess  of 
that  required  in  the  structure  of  tissues,  and  without  which  the 
said  materials  cannot  be  absorbed.  Cai'bonic  acid — required  to 
be  present  in  the  water  for  the  easier  solution  of  bone,  earth, 
carbonate  of  lime,  and  albuminous  food  which  contains  them. 
Pepsine,  to  replace  deficient  gastric  juice.  Lactic  acid — re- 
quired in  the  stomach  to  acidify  the  mass  and  enable  the  albu- 
men to  be  acted  upon  by  the  gastric  juice.  This  may  be  replaced 
by  other  acids,  such  as  hydrochloric,  or  acetic,  or  malic,  for  ex- 
ample, in  some  cases.  Bile,  in  the  form  of  inspissated  ox-gall, 
or  liquid  ox-gall  in  capsules,  to  supply  the  place  of  that  which  is 
arrested  in  its  passage  or  in  its  formation  by  disease.  Pancre- 
atine, similar  to  pepsine. 


DISEASE  AND  CURE.  45 

4th.  Excitants  of  digestive  solvents. — Mineral  acids  mixed 
with  the  food  increases  the  flow  of  bile ;  indeed  all  acid  sub- 
stances have  the  power  of  exciting  alkaline  secretions.  Thus 
they  are  useful,  not  only  in  jaundice  from  suppression,  but  in 
many  cases  of  indigestion  where  this  solvent  is  too  sparingl}'- 
formed.  In  many  cases,  too,  of  flatulence  from  fermentation  of 
the  ingesta,  mineral  acids  are  beneficial,  by  causing  the  pouring 
out  into  the  intestinal  canal  of  bile  which  arrests  putrefaction. 
Alkalies,  on  the  other  hand,  will  also  increase  the  flow  of  bile. 
Perhaps  it  is  that  they  supply  one  of  its  constituents ;  perhaps 
(as  Dr.  Harley  explains  it)  they  stimulate  a  secretion  of  gastric 
juice,  according  to  a  converse  law  to  that  quoted  in  respect  of 
mineral  acids,  and  this  gastric  juice  excites  the  bile-flow.  It  is 
obvious  that  to  accomplish  this  object,  alkalies  must  be  taken  on 
an  empty  stomach,  otherwise  they  are  wasted,  or  rather  do  harm, 
by  neutralizing  the  acid  already  mixing  with  the  ingesta.  Sugar, 
peppers,  mustard^  spices,  and  other  condiments,  act  in  a  mode- 
rate degree  in  the  same  way,  as  may  be  seen  by  the  effects  on 
the  saliva;  but  their  influence  is  limited.  Ease  of  mind,  or 
cheerful  conversation,  excite  the  gastric  juice  ;  or,  I  should  rather 
say,  they  prevent  the  opposite  state  of  mind  which  retards  the 
secretion.  Oxygen  has  a  direct  effect  in  exciting  the  flow  of  all 
the  digestive  solvents  from  the  saliva  downwards.  Water  in- 
creases their  quantity  in  the  same  way  that  it  adds  to  the  solid 
bulk  as  well  as  to  the  liquid  bulk  of  all  secretions. 

5th.  Artificial  replacement  of  wanting  vital  functions. — The 
normal  animal  warmth  is  a  great  element  in  promoting  normal 
reconstructive  growth.  We  know  how  much  more  readily  inter- 
nal wounds  heal  than  external  wounds ;  how  much  more  quickly, 
when  they  have  been  carefully  covered  up  and  kept  at  an  even 
temperature,  than  when  they  have  been  laid  open  to  the  vary- 
ing influences  of  the  variable  air.  Disease  lowers  the  power  of 
producing  heat  in  the  diseased  tissue,  or  it  causes  heat  to  be 
produced  in  a  fitful  irregular  way.  An  even  artificial  lieat  is 
therefore  a  strong  means  of  renewing  life.  Where  vitality  is 
deficient  throughout  the  whole  body,  we  can  economize  it  by 
clothing  impervious  to  atmospheric  changes,  as  woolen,  silk, 
4 


46  DISEASE  AND  CURE. 

&c.,  and  by  avoiding  linen,  as  in  albuminuria  among  chronic 
diseases,  and  in  acute  rheumatism  among  acute.  Where  there 
is  a  local  deficiency  of  vitality,  as  in  pneumonia,  pleurisy,  peri- 
carditis, peritonitis,  ulcerated  bowels,  &c.,  none  of  our  cura- 
tive appliances  are  so  important  as  a  continuous  poultice.  Warm 
baths  supply  a  large  quantity  of  assimilable  heat,  which  lasts 
for  a  considerable  time,  and  hence,  in  certain  cases,  they  are 
felt  as  a  tonic.  But  they  will  only  suit  patients  who  are  bene- 
fited, or  at  least  not  injured,  by  the  absorption  of  a  great  deal 
of  water. 

Electricity  supplies  the  contractile  muscular  fibers  with  a  stimu- 
lus to  action  which  is  wanting  in  cases  of  deficient  nerve-force. 
Hence  it  keeps  up  the  habit  of  motion  in  paralytic  limbs,  pre- 
vents their  getting  atrophied,  and  sustains  them  in  a  state  of 
possible  activity  till  such  time  as  the  injured  nerve-force  recover 
itself.  Artificial  motion  and  rubbing  act  much  in  the  same  way. 
Mechanical  aids  to  sight,  sound,  hearing,  and  movements,  rightly 
employed,  may  come  under  the  same  category. 

6th.  A  temjyorary  revival  of  deficient  functions. — For  example, 
the  deepening  of  sluggish  breathing  by  ammonia,  valerian  ethers, 
and  essential  oils.  This  stimulation,  though  it  may  be  only  tem- 
porary upon  the  organ  directly  acted  upon,  and  is  therefore  fol- 
lowed by  a  reactionary  collapse;  yet  indirectly  it  contributes  to 
life  by  the  influence  of  the  organ's  functions  upon  other  parts. 
Thus  the  deepening  of  the  breathing,  instanced  just  now,  aerates 
the  blood  and  strengthens  the  circulation,  and  so  makes  to  the 
capital  of  life  an  addition  which  lasts  long  after  the  passing 
stimulus  has  lapsed  into  a  corresponding  degree  of  deficiency. 
Perhaps  the  permanent  benefit  of  warm  bathing,  often  so  much 
greater  than  can  be  accounted  for  by  the  short  increase  of 
warmth,  may  be  explained  in  the  same  way.  Alcohol  often  acts 
beneficially  in  full  doses  at  long  intervals,  in  cases  where  its  con- 
tinued influence  in  smaller  doses  would  be  hurtful,  probably  on 
this  same  principle.  But  as  a  general  rule,  those  stimulants  are 
to  be  preferred  for  the  purpose  whose  effect  is  more  transient. 

7th.  Increasers  of  absorption  are  constructive  medicines. 
Vegetable  bitters  brace  up  and  harden  the  mucous  membranes. 


DISEASE  AND  CURE.  47 

aa  may  be  easily  tried  by  their  effect  on  the  mouth.  Hence 
exosmosis  is  lessened,  and  endosmosis  increased.  Digestion  is 
made  more  rapid  and  effectual,  nutriment  is  taken  up  more 
copiously  and  quicker.  Even  in  a  healthy  person  the  remains 
of  the  List  meal  are  sooner  disposed  of,  and  the  appetite  for  the 
next  sharpened  by  a  bitter.  This  is  the  pure  action  of  a  vege- 
table tonic;  but  a  good  many  of  the  plants  we  use  as  such  con- 
tain various  matters  which  otherwise  unfit  them  for  our  purposes 
in  certain  cases.  Perhaps  none  exercise  so  few  of  these  noxious 
influences  and  are  more  generally  applicable  than  the  products 
of  the  inimitable  cinchona.  Astringents  also  may  reasonably 
have  some  of  their  beneficial  influence  on  the  digestive  canal 
explained  by  their  restraining  the  formation  of  mucus.  When 
mucus  is  in  excess,  it  doubtless  interferes  much  with  the  taking 
up  of  nutriment  by  membranes,  and  the  checking  its  growth  is 
an  indirectly  constructive  act.  Many  of  the  vegetable  bitters 
contain  tannin  or  other  astringent  constituents,  and  are  thus 
peculiarly  suited  to  the  leucophlegmatic  (or  mucogenous)  dia- 
thesis. These  drugs  are  suitable  not  only  for  the  digestive  canal, 
but  to  other  internal  tegumentary  membranes.  Thus  the  renewal 
of  life  in  the  uterus  and  ovaria  is  very  much  aided  by  checking 
leucorrhoea  with  astringent  injections.  The  absent  catamenia 
will  often  reappear  while  the  weakening  discharge  is  being  thus 
arrested;  and  stagnant  ulcers  will  form  fresh  healthy  tissue, 
wounds  will  close,  and  abscesses  heal  after,  nay,  during  the 
application  to  them  of  astringents.  Sulphate  of  copper  and 
nitrate  of  silver  are  most  active  in  this  waj  ;  but,  as  you  know 
well  from  your  experience  as  dressers,  heed  must  be  taken  lest 
when  destroying  the  mucus  and  pus-formation  you  also  destroy 
the  life  of  the  adjoining  tissues  whose  preservation  is  your  care. 
Sulphate  of  copper  is  a  most  powerful  internal  medicine,  as  a 
reviver  of  health  in  ulcerated  parts  of  the  intestinal  canal,  and 
it  also  seems  to  act  as  a  tonic  generally  to  the  digestive  tract. 
Nitrate  of  silver  would  probably  be  equally  useful,  but  unhappily 
it  is  too  soon  converted  into  the  inert  chloride  by  the  salt  of  the 
secretions. 

8th.  Excitajits  of  the  involuntary  muscles  which  subserve  ab- 


48  DISEASE  AND  CURE. 

sorption  are  also  constructives.  Thus  strychnia  and  aloes  in- 
crease the  appetite  by  hastening  the  passage  of  the  alimentary 
mass,  and  this  joined  to  their  bitterness  makes  them  tonics. 
But  they  both  are  better  Avhen  aided  by  other  tonics.  Suc- 
cussion  stimulates  these  muscles,  and  so  very  gentle  exercise 
promotes  digestion,  but  violent  muscular  exertions  arrest  it, 
because  they  engage  the  nervous  energy  elsewhere. 

There  are  certain  reagents  which,  in  a  manner  as  yet  quite 
unexplained  by  physiology,  appear  to  alter  towards  health  par- 
ticular tissues.  They  are  not  constituents  of  the  body,  nor  do 
they  seem  suited  to  take  the  place  of  constituents  of  the  body, 
nor  do  they  cause  any  evacuation  of  retained  eflFeta,  nor  do  they 
apparently  act  on  any  of  the  healthy  organs.  Iodine  and  bro- 
mine, for  example,  have  this  effect  on  the  white  fibrous  tissues, 
and  as  they  originate  renewal,  I  can  hardly  help  classing  them 
among  constructives. 


With  Destructives  our  forefathers  have  left  us  well  ac- 
quainted. Time  out  of  mind  the  Avorld  has  had  long  lists  of 
articles  of  materia  medica,  classified  according  to  the  organs 
through  whose  gates  they  disgorge  the  products  of  metamor- 
phosis. "Sudorifics,"  "purgatives,"  "diuretics,"  "expecto- 
rants," &c.,  are  familiar  to  both  doctors  and  the  unlearned; 
while  others,  as  mercury  for  examj^le,  are  known  as  general 
"liquefacients,"  promoting  destructive  metamorphosis  univer- 
sally, and  a  consequent  increase  of  solid  evacuation  from  all 
quarters.  And  other  expedients  again,  such  as  bleeding,  are  a 
direct  mechanical  abstraction  of  a  part  of  the  living  body. 

The  uses  of  Destructives  are  the  following : 

1st.  To  remove  from  the  system  effete  matters  lohich  are  toxi- 
cally  noxious  to  healthy  life.  Nothing  does  this  so  universally 
as  water.  The  biliverdin  which  we  see  staining  the  skin  in 
jaundice,  and  which  indicates  also  the  presence  of  the  more 
injurious  biliary  acids,  may  be  removed  by  mercurials^  by  podo- 
jphyllin,  by  soda^  and,  according  to  Dr.  Harley,  by  benzoic  acid, 
provided  always  care  be  taken  that  the  passage  for  their  exit  is 


DISEASE  AND  CURE.  49 

free,  that  the  bile  ducts  are  not  obstructed.  So  also  uric  acid 
may  be  eliminated  from  the  blood  by  nitre  and  by  some  other 
neutral  salts,  when  the  kidneys  are  healthy  and  neither  degene- 
rated nor  congested.  In  applying  these  remedies  it  is  necessary 
to  see  clearly  what  is  the  effete  matter  we  wish  to  get  rid  of,  and 
to  use  the  appropriate  agent.  No  laborers  in  the  present  field 
of  practical  medicine  deserve  so  well  of  the  world  as  those  who 
make  it  their  business  to  inquire  into  the  real  intimate  working 
of  our  tools.  The  chemists'  shops  are  quite  full  enough,  and  it 
adds  much  more  to  true  useful  knowledge  to  make  a  single  step 
towards  explaining  the  action  of  one  established  remedy  than  to 
add  a  hundred  articles  to  the  pharmacopoeia.  One  would  be 
glad  to  know  in  the  case  of  each  eliminating  drug  which  of  the 
efi'ete  constituents  it  most  readily  acts  upon.  Thus  much  milder 
medicines  might  often  be  employed,  which  would  go  straight  to 
the  point,  instead  of  exercising  in  addition  some  violent  but  un- 
necessary action.  Do  not  let  us  rest  satisfied  with  the  nomencla- 
ture of  "purgatives,"  "diuretics,"  "sudorifics,"  if  it  is  possible 
to  discover  what  it  is  they  purge  out,  what  constituent  is  specially 
removed  through  the  kidneys  and  what  through  the  skin  by  the 
augmented  secretion. 

2d.  To  remove  inechanical  impediments  to  normal  excretio7i. 
The  proviso  which  I  made  just  now  in  the  case  of  the  liver  and 
kidneys,  namely,  that  their  should  be  nothing  in  their  structural 
state  which  can  impede  the  flow  of  bile  or  the  urinary  constituents, 
reminds  us  of  another  use  for  destructives.  For  example,  leeches 
on  the  right  hypochondrium  will  often  restore  a  flow  of  bile,  in 
diminishing  a  congestion  of  the  hepatic  tissue  by  which  its  for- 
mation may  be  stayed.  Cupping  the  loins  will  act  as  a  diuretic 
by  relieving  congestion  of  the  kidneys  after  scarlatina  or  other 
cause.  Leeches  to  the  anus,  or  artificial  hsemorrhoids,  will  empty 
the  stagnant  portal  circulation,  resuscitate  its  activity,  and  by 
this  means  enable  medicines  to  be  absorbed  and  food  to  be 
digested.  General  bleeding  will  at  a  great  expense  to  the 
system,  and  not  perhaps  more  readily,  effect  all  these  objects  at 
once.     The  advantage  of  venesection  to  our  forefathers  was  that 


50  DISEASE  AND  CURE. 

it  did  not  require  any  accuracy  of  diagnosis  of  the  organ  to  be 
attacked,  but  made  a  general  assault  on  all  together. 

3d.  The  removal  of  impediment  to  absorption  is  another  good 
reason  for  the  administration  of  sundry  destructive  medicines. 
This  is  often  merely  a  question  of  mechanics,  and  if  we  could 
apply  mechanical  means  to  the  required  locality,  they  often 
would  do  better.  Such  for  example  is  the  removal  from  the 
stomach  and  intestinal  canal  of  mucus,  Avhether  peopled  with 
parasitic  worms  or  not.  Mucus  is  in  itself  peculiarly  insoluble, 
and  therefore  indigestible,  and  it  also  firmly  resists  diosmose: 
thus  its  presence  stands  in  the  way  of  the  absorption  of  nutri- 
ment by  the  digestive  membranes.  It  is  not  easy  to  rid  the 
patient  of  these  incumbrances  without  abnormally  augmenting 
destructive  excretion,  but  if  it  can  be  done  we  should  be  glad 
to  do  it. 

4th.  The  removal  of  systemic  poisons  which  are  the  cause  of 
disease  by  destructives  seems  shown  to  be  possible  by  the  effect 
of  mercury  on  the  syphilitic  virus.  The  body  is  endowed  with 
power  to  gradually  eliminate  this  virus,  and  after  a  course  of 
diseased  states  of  long,  perhaps  years  long  duration,  to  return 
again  to  health.  Indeed  if  it  had  not  this  power,  remedies 
would  be  useless;  for  drugs,  though  they  can  arouse  sluggish 
capabilities,  can  bostow  none  not  originally  inherent  in  the 
nature.  The  natural  elimination,  tedious  always  and  perhaps 
sometimes  otherwise  impossible,  is,  according  to  Mr.  Lee  and 
other  experienced  syphilographers  of  late  years,  much  quickened 
by  mercury.  Mercury  does  not,  like  sarsaparilla,  bark,  iodide  of 
potassium,  and  other  constructives,  benefit  by  curing  the  diseases 
caused  by  the  virus ;  it  aids  the  system  to  destroy  the  virus 
itself.  That  it  should  do  so  is  not  surprising  when  we  see  its 
wonderful  destructive  action  on  animal  tissues;  how  they  become 
softened  and  blanched  and  dwindled  in  decay  when  the  system 
is  saturated  with  the  metal. 

Were  there  any  other  chronic  diseases  so  indubitably  kept  up 
by  the  obstinate  adhesion  in  the  system  of  a  morbid  poison,  it 
might  be  worth  while  to  destroy  the  poison  in  the  same  way. 
It  might  be  worth  while  to  submit  to  having  the  healthy  parts 


DISEASE  AND  CURE.  51 

of  the  body  scotched,  for  the  sake  of  prematurely  killing  its 
baleful  guest ;  but  I  do  not  think  we  can  find  another  instance 
among  maladies  common  enough  for  us  to  be  well  acquainted 
with  their  pathology. 

In  acute  fevers  dependent  on  organic  poison  the  system  casts 
it  forth  so  quickly  that  sometimes  danger  is  born  of  its  very  haste 
and  effervescence.  We  should  be  at  no  pains  to  hurry  the  process, 
although  we  might  possess  the  capability  of  doing  so.  Under  the 
same  restrictions  as  morbid  poisons  comes  the  removal  of  inde- 
pendent parasites,  such  as  lice,  itch  acari,  the  fungi  of  favus  and 
pityriasis  versicolor,  of  dead  or  incurable  parts  of  the  body  which 
react  upon  and  become  the  causes  of  diseases,  and  of  foreign 
matters  generally.  We  must  balance  the  injury  Ave  may  be 
obliged  to  inflict  in  removing  them  against  the  good  done  by 
such  removal. 

A  free  review  of  the  rational  reasons  for  using  destructive 
treatments  in  the  cases  I  have  given  as  examples,  will  confirm 
the  universal  rule  that  they  are  never  to  be  employed  for  their 
own  sake,  but  only  to  either  make  room  for,  or  to  give  play  to 
constructive  growth. 


Arresters  of  constructive  life,  as  such,  can  scarcely  come 
under  the  denomination  of  medicines;  physicians  never  wish  to 
stop  growth  in  human  patients.  As  poisons  we  do  use  them  on 
animals  for  certain  purposes  of  our  own:  alcohol  is  given  to 
puppies  to  keep  them  small  dogs;  and  it  is  stated  that  dwarf- 
like jockeys  have  been  produced  by  the  same  treatment.  We 
have  thus  a  warning  of  what  the  effect  of  the  agent  is. 

The  same  article  of  diet,  however,  appears  in  another  light 
as  an  arrester  of  destruction.  We  not  selaom  wish  to  stay  the 
process  of  vital  decay  in  our  patients,  and  are  provided  with  a 
means  of  doing  so  in  alcohol.  In  a  lecture  published  some  time 
ago*  I  explained  the  reasons  for  thus  viewing  alcohol,  entering 

*  See  Lectures  XLVII  and  L  of  this  edition.  I  take  this  opportunity  of  say- 
ing that  the  lectures  are  not  placed  in  the  order  in  which  they  were  delivered. 
Clinical  instruction  is  of  course  given  as  the  cases  occur ;  so  that  the  student 


52  DISEASE  AND  CURE. 

into  details  of  the  circumstances  -which  should  guide  and  govern 
its  administration;  and  I  have  not  time  to  repeat  them  now. 
I  have  there  classed  it  as  an  anaesthetic,  whose  primary  action 
is  on  the  nervous  system,  and  attributed  to  that  action  its  eiFect 
in  staying  destructive  metamorphosis. 

Our  other  more  generally  acknowledged  anaesthetics  have  a 
similar  action;  they  prevent  the  wearing  out  of  the  body  by  the 
painful  and  destructive  functioning  of  the  nervous  system  during 
disease. 

Why  is  the  functioning  of  the  nervous  system  during  disease 
painful  and  destructive  ?  It  seems  to  me  that  M.  Chossat's 
experiments  throw  some  light  on  this  obscure  subject.  The 
nervous  system  is  the  ^'- ultimum  moriens" — the  member  of  the 
body  the  least  affected  by  vital  decay,  that  upon  which  starva- 
tion, deficiency  of  life,  disease,  have  least  decomposing  influence. 
It  remains  therefore  energetic,  sensitive,  and  motive,  whilst  the 
others  become  deadened  and  sluggish.  Thus  the  due  balance  of 
the  functions  is  overthrown.  By  a  restriction  placed  upon  the 
normal  but  inconvenient  force  of  the  nervous  system  we  get  a 
state  more  like  to  health,  by  reason  of  its  nearer  approach  to 
balance,  and  guard  the  tissues  against  the  disorganizing  tendency 
of  its  abnormal  disturbance. 

The  same  aim  of  restoring  the  balance  may  be  effected  by 
raising  the  depressed  vitality  of  the  non-nervous  deficient 
functions.  And  where  this  can  be  done,  of  course  it  is  the 
best  treatment.  Where  means  of  accomplishing  such  a  desirable 
object  are  wanting,  anaesthetics  are  the  next  best  resource.  Just 
as  in  machinery  when  a  wheel  has  got  worn  and  inefficient,  it  is 
best  to  put  in  a  new  one,  if  possible ;  but  where  we  cannot,  we 
slacken  the  steam  power — quod  opibus  deest,  arte  sareimus. 

may  come  fresh  from  the  bedside  observation  of  the  patient  to  the  deductions 
made  therefrom.  Introductories,  however,  at  the  opening  of  each  session,  aflford 
a  legitimate  opportunity  for  a  systematic  statement  of  principles,  for  going  back 
to  the  abstract  truths  which  are  the  result  of  previous  practice  and  experience. 
To  the  reader  it  is  convenient  that  these  should  come  together  at  the  beginning 
of  the  volume;  and  the  sequence  of  time  being  thus  disturbed,  I  have  preferred 
to  set  the  rest  in  a  sort  of  natural  order,  putting  together  those  which  seemed  to 
have  most  bearing  on  one  another,  rather  than  to  arrange  them  chronologically. 


DISEASE  AND  CURE.  53 

Is  pain  the  expression  of  the  want  of  balance  I  have  spoken 
of,  or  is  it  only  a  co-ordinate  phenomenon?  Certain  it  is  that 
pure  pain,  such  as  neuralgia,  is  relieved  either  on  raising  the 
vital  functions  with  food,  tonics,  &c.,  or  on  blunting  the  nerves 
with  anaesthetics. 

Remark  now  that  destructives  and  arresters  are  not  in  any 
case  final  treatment;  the  end  is  in  every  in<*tance  reconstruction 
or  renewal — an  aim  which  must  be  kept  in  view  in  all  the  phy- 
sician does  or  counsels. 

These  principles  of  therapeutics  I  make  it  the  business  of  my 
clinical  lectures  to  enforce  and  illustrate  by  the  examples  of  dis- 
ease which  are  at  the  moment  passing  under  your  eyes.  Do  not 
suppose  these  examples  to  be  picked  examples — cases  selected 
to  prove  my  points:  no — each  one  of  my  patients  in  the  wards 
teaches  the  same  lessons  to  all,  at  least  to  all  those  who  are  will- 
ing to  be  taught  by  nature  rather  than  by  books.  Let  me  en- 
treat of  you  not  to  neglect  the  opportunity  which  is  afforded  by 
our  liberal  public  charities  and  the  independence  of  your  pupil- 
age to  learn  truth,  and  then  you  will  not  fail  in  after  years  to 
practice  it. 


LECTURE   III. 

THE  FORMATION  OF  MUCUS  AND  PUS. 

Offiee  of  mucous  membranes — The  identity  of  mucous  globules 
and  nascent  ejnthclium — Self-supported  growth  of  mucous 
globules — Similar  to  organic  groivth  of  a  imrasite — Is  this 
form  of  life  an  excess  or  a  deficiency  of  normal  life? 

{First  Lumleian  Lecture  at  the  College  of  Physicians,  Lent,  1863.) 

The  subject  which  I  have  chosen  for  these  Lumleian  Lectures 
is  one  which  must  be  interesting  to  physicians  above  all  other 
observers  of  nature,  for  in  very  few  indeed  of  the  cases  minis- 
tered to  by  us  has  not  either  the  cause  of  the  death  acted  on  the 
body  through  these  integumentary  coverings,  or  manifested  its 
action  by  a  perversion  of  their  functions.  The  majority  of  our 
medicines  are  intended  to  act  on  mucous  membrane,  and  all  are 
introduced  into  the  body  through  it.  We  cannot  therefore  but 
be  grateful  to  those  who  have  endeavored  to  add  to  our  knowl- 
edge of  its  nature  and  habits. 

The  term  by  which  it  is  conventionally  designated  is  apt  to 
lead  the  most  thoughtful  of  us  into  a  fallacy.  Active  members 
of  society  are  named  after  the  work  which  is  their  most  import- 
ant occupation.  The  industry  of  the  lawyer  is  the  administra- 
tion of  the  "law;"  the  doctor  is  most  efficient  when  he  is  most 
"learned;"  the  duty  of  bishops  and  overseers  is  kmaKontiv,  "to 
oversee"  each  their  several  departments.  But  the  office  of 
mucous  membrane  is  not  to  secrete  mucus.  It  is  most  active 
Avhen  it  is  not  doing  so,  and  its  activity  is  decreased  just  in  pro- 
portion to  the  copiousness  of  the  mucus.  Typical  health  cer- 
tainly consists  in  its  absence;  many  robust  people  pass  weeks 
without  expectorating;  many  find  their  handkerchiefs  clean  and 


THE  FORMATION  OF  MUCUS  AND  PUS.  55, 

unrumpled  after  being  clays  in  their  pockets,  in  spite  of  all  the 
artificial  and  accidental  irritants  to  which  the  Schneiderian  mem- 
brane is  subject;  and  the  urinary  and  intestinal  canals  contribute 
only  an  infinitesimal  quantity,  which  may  fairly  be  attributed  to 
a  temporary  departure  from  health  of  some  fraction  of  their  large 
area. 

The  business  of  mucous  membrane  is  to  offer  a  passage  for 
oxygen,  "water,  fat,  albumen,  and  other  useful  substances,  and 
to  defend  the  less  easily  renewed  tissues  beneath  it  from  the  de- 
leterious action  of  external  agents.  These  functions  it  best  ful- 
fills when  it  is  bedewed  with  a  moderate  exhalation,  and  not  with 
mucus. 

This  exhalation  is  transparent  and  aqueous,  exhibiting  nought 
of  that  stringy  adherent  character  by  which  we  ordinarily  recog- 
nize the  substance  known  as  mucus.  It  carries  out  with  it  the 
epithelium  scales  shed  or  moulted  from  the  surface;  and  these 
scales  are  consequently  found  in  the  excretions ;  but  it  is  itself 
absorbed  again  as  quickly  as  it  is  exhaled,  and  docs  not  con- 
tribute to  the  substance  of  any  of  the  ejecta  of  the  body.  The 
typical  healthy  condition  of  a  mucous  membrane  may  be  con- 
sidered to  be  a  constant  dampness  without  visible  fluid,  and  a 
moderate  and  gradual  shedding  of  epithelium. 

Shed  epithelia  in  a  complete  form  are  found  also  in  mucus, 
but  not  so  as  to  modify  its  physical  properties.  Its  most  obvious 
characteristic  is  the  presence  of  transparent  bodies,  apparently 
of  a  gelatinous  consistence,  of  a  more  or  less  rounded  or  oval 
form,  and  with  one  or  more  nuclei,  seemingly  of  a  less  trans- 
parent consistence,  in  their  interior.  But  its  physical  properties 
of  consistence  and  adhesiveness,  which  so  peculiarly  distinguish 
it  from  all  other  transparent  fluids,  seem  to  be  derived  from  the 
medium  in  which  these  globules  are  placed.  This  origin  may 
be  inferred  because  similar  globules,  quite  undistinguishable  in 
appearance  and  behavior,  constitute  also  the  bulk  of  pus,  a  fluid 
of  quite  distinct  attributes  and  properties. 

There  are  probably  no  observations  more  suggestive  and  luci- 
ferous  to  rational  medicine  than  those  contained  in  the  paper  of 
Henle,  published  about  a  quarter  of  a  century  ago  in  Hufeland's 


;3G  THE  FORMATION  OF  MUCUS  AND  PUS. 

Journal.  It  is  an  excellent  example  of  physiological  reasoning, 
and  later  observation  seems  to  set  the  matters  of  which  it  deals 
beyond  reasonable  doubt. 

Professor  Henle's  argument  aims,  successfully  I  think,  at 
tracing  the  globules  which  are  seen  in  mucus  under  the  micro- 
scope to  that  substance  which  in  the  normal  state  of  typical  per- 
fection would  form  epithelium.  They  appear  to  be  young  epi- 
thelium arrested  in  its  growth,  and  prematurely  moulted  oif  from 
the  body.  The  condition  which  produces  them  is  an  arrest  of 
development. 

To  feel  the  full  force  of  the  experiments  and  observations 
which  confirm  this  view,  it  is  necessary  to  see  the  connecting 
links  of  resemblance  which  run  through  the  course  of  the  integu- 
mentary membranes.  We  must  pass  over  for  the  nonce  the  dif- 
ferences which  fit  for  their  various  uses  the  external  skin,  the 
coverino;  of  the  tongue  and  mouth,  the  secretinoj  lining  of  the 
stomach,  the  absorbing  lining  of  the  intestines,  the  defensive 
coats  of  the  bladder,  urethra,  rectum,  &c.  We  must  look  upon 
them  as  one  whole.  Just  as  the  skin  clothes  the  muscular  frame- 
work of  the  body,  moulded  on  the  form  of  the  skeleton,  so  the 
mucous  membrane  lines  the  internal  canals,  pits,  and  galleries, 
following  their  intricate  windings  throughout.  And  for  exactly 
the  same  purpose — namely,  to  be  a  defensive  medium  of  com- 
munication between  the  individual  being  and  the  outer  world, 
between  the  microcosm  and  the  megalocosm,  in  all  their  chemical 
and  mechanical  relations  to  one  another. 

For  the  fulfillment  of  this  common  duty  they  have  a  common 
structure.  Strip  off  a  piece  of  epidermis,  and  you  find  that  its 
outermost  layer  consists  of  flat  polygonal  scales  pressed  close 
together  and  united  both  by  the  edges  and  surfaces  so  as  to  form 
a  continuous  leathery  tissue.  They  are  welded  into  one  fabric 
like  the  exposed  part  of  an  old  macadamized  road.  But  just  as, 
when  you  pick  up  the  surface  of  this  road,  you  expose  a  deeper 
layer  of  stones  loose  and  separate,  so  beneath  the  scarf  skin  you 
find  what  Malpighi,  Avith  philosophical  prescience,  called  the 
rete  mucoHum.  This  consists,  like  the  scarf  skin,  of  separate 
corpuscles,  which,  like  the  stones  of  the  macadamized  road,  be- 


THE  FORMATION  OF  MUCUS  AND  PUS.  57 

come  looser  in  structure,  less  adherent,  and  less  similar  to  tlie 
upper  layers  as  you  go  deeper.  The  superior  corpuscles  are, 
indeed,  flattened,  and  exhibit  a  flattened  nucleus  inclosed  in  a 
clear  cell  as  an  epidermoid  scale.  But  as  you  get  nearer  the 
cutis  the  nuclei  are  rounder  and  rounder,  and  the  transparent 
area  of  the  cell  is  less  and  less  visible;  until  at  last,  on  the  cutis, 
the  corpuscles  are  seen  to  consist  of  only  granular  masses.  These 
granular  masses  are  identical  with  those  seen  in  mucus. 

Just  in  the  same  Avay  the  mucous  membranes  arc  clothed  with 
epithelium,  loosely  scaly  in  some  parts,  Avoided  together  like  a 
macadamized  pavement  in  another,  columnar  in  another.  And 
when  this  is  stripped  off  or  injured,  there  are  brought  into  view 
floating  granular  masses  of  various  sizes,  Avhich  constitute  what 
are  familiarly  known  as  "mucous  globules."  They  are  exactly 
identical  with  the  inner  strata  of  the  epidermis,  the  rete  mucosuiu 
of  Malpighi. 

What  are  these  globules?  Are  they  something  special,  be- 
longing to  special  tissues,  and  appearing  only  under  special  cir- 
cumstances? Or  are  they  a  form  of  organic  matter  common  to 
other  parts  also?  Are  we  to  apply  here  the  Baconian  myth  of 
Proteus,  and  look  for  their  natura  naturcms  as  exhibited  else- 
where in  various  shapes?     It  think  it  is  philosophical  to  do  so. 

The  appearance  they  have  is  that  of  all  matter  when  it  first 
puts  on  life.  The  telescope  and  the  microscope  equally  reveal 
to  us  these  nebulae  as  the  earliest  indication  of  vitality,  drawing 
the  surrounding  chaos  towards  a  central  point,  then  exhibiting 
that  central  point  as  a  kernel  or  nucleus.  And  then  this  kernel 
becomes  the  parent  of  new  centers,  individual  and  separate,  and 
these  again  starting  places  of  new  action.  The  dawn  of  vitality 
is  exhibited  in  the  coalescence  of  molecules  of  organic  matter  so 
as  to  form  nuclei,  which,  under  favorable  circumstances,  develop 
either  separate  cells  or  tissues. 

Up  to  this  point  each  focus  of  life  seems  to  be  a  separate  in- 
dividual. It  takes  in  nourishment  by  its  innate  power  from 
without;  it  increases  in  size  and  alters  in  shape.  And  this 
alteration  in  shape  seems  principally  to  take  place  from  within. 
It  is  not  merely  an  aggregation  outside  of  ncAV  molecules,  but  a 


58  THE  FORMATION  OF  MUCUS  AND  PUS. 

plastic  change  of  internal  appearance.  Nay  more,  it  possesses 
the  faculty  of  giving  birth  to  an  individual,  and  so  to  a  succession 
of  individuals,  like  itself.  No  better  evidence  of  automatic  exist- 
ence can  probably  be  given. 

These  phenomena  can  be  seen  without  much  difficulty  in  the 
globules  of  mucus.  That  which  answers  best  is  what  we  often 
expectorate  in  little  semi-transparent  gelatinous  lumps  from  the 
bronchi  in  the  morning  after  exposure  to  night  air.  This  must 
not  be  mixed  with  water,  or  be  allowed  to  cool,  but  kept  at  the 
temperature  of  the  body,  and  put  immediately  under  a  lens  of 
as  high  a  power  as  you  can  command.  Dr.  Beale  showed  me  the 
phenomena  first  under  a  24th,  but  I  have  seen  them  very  well 
under  an  8th  inch  in  an  old-fashioned  Powel's  microscope.  Keep 
your  eye  fixed  on  one  nuclear  mass,  and  you  will  often  see  a 
gradual  change  in  its  appearance.  First  a  clearer  nucleus  ap- 
pears in  it;  then,  as  you  gaze,  two,  three,  or  more  smaller  nuclei. 
Then  the  fine  granular  sj^ecks  in  its  sides  coalesce  into  a  nucleus. 
Then  you  see  that  it  has  a  bulge  in  its  side,  and  that  a  nucleus 
forms  a  bud,  and  then  has  a  constricted  neck  or  stalk.  And 
then,  perhaps,  if  you  are  lucky  enough  to  get  the  mucus  in 
motion  without  losing  sight  of  your  object,  the  bud  may  float  oif 

as  a  separate  globule.  Or  the 
-■■»"''''°^^!t?^  .-."*»'«  ^'i5i^  ^f'-'^^^A  whole  globule  may  divide  into 
^y'^^iiW      0§i{^  "|iV^'"v^  two,  each  with  a  separate  nucleus, 

"<^^  as  i  have  tried  to  represent  m 
this  drawino;  from  life  of  five 
globules  in  this  state  of  tran- 
sition. 

A  temperature  below  that  of  the  body  seems  to  check  this  de- 
velopment, but  you  may  often  keep  it  on  by  means  of  a  spirit- 
lamp.  The  globules  in  which  I  have  seen  it  take  place  are  those 
from  the  trachea,  from  the  os  uteri,  and  from  warm  freshly- 
passed  urine  in  cases  of  inflamed  bladder. 

When  the  fluid  has  got  dried  up  by  the  heat  thus  constantly 
applied,  you  may  in  some  degree  restore  its  activity  by  moisten- 
ing it  with  a  viscid  animal  fluid,  such  as  saliva.  The  greater 
part,  indeed,  is  broken  up  into  molecules,  and  these  show  no 


THE  FORMATION  OF  MUCUS  AND  TUS.  59 

disposition  to  unite  into  globules,  but  among  them  will  remain 
some  globules  unbroken,  and  these  will  again  form  new  nuclei, 
and  bud  as  they  did  at  first. 

Is  this  organic  growth?  Or  is  it  the  aggregation  intovislble 
masses  of  particles  already  existing,  like  that  which  Mr.  Rainey 
has  described  as  taking  place  in  mineral  matters?  Is  it  a  mere 
coalescence,  or  something  more?  I  must  say  that  to  my  mind 
the  production  of  an  individual  like  itself,  capable  again  of  re- 
producing another  individual  still  resembling  the  grandmother 
globule,  is  identical  with  organization.  And  I  think,  too,  that 
the  multiplication  of  the  nuclei  inside  is  quite  unlike  any  sort  of 
coalescence,  which  would  add  matter  to  the  outside,  like  an 
urinary  calculus  or  an  avalanche. 

It  seems  to  me  that  each  of  the  globules  contains  a  center  of 
life,  into  which  the  pabulum  passes  from  the  outside,  nourishing 
them  and  giving  them  means  to  increase  in  number.  This  would 
account  for  the  enormously  rapid  collection  of  mucus  filled  with 
globules  on  inflamed  membranes,  even  on  membranes  which  in 
the  healthy  state  shed  very  little  epithelium,  or  have  but  one 
layer  of  it,  as  in  the  bronchi,  and  therefore  cannot  be  supposed 
naturally  to  form  much  young  epithelium.  The  first  parent 
globules  may  be  aborted  young  epithelium  cells,  and  these  may 
be  the  ancestors  of  others  which  form  the  bulk  of  the  mucus, 
begetting  them  with  the  extreme  rapidity  characteristic  of  gene- 
ration in  low  organic  life. 

If  this  be  true,  mucus  may  be  viewed  as  a  parasite,  receiving 
from  the  body  its  nutriment  indeed,  but  not  its  form  nor  its  claim 
to  vitality. 

Doubtless  the  growth  of  mucus  is  most  rapid  where  there  is 
normally  a  thick  layer  of  epithelium,  and  where  a  large  growth 
of  young  epithelium  is  constantly  being  formed  to  replace  the 
rapid  moulting.  But  still  it  is  much  quicker  on  localities  with 
a  thin  layer  than  could  be  accounted  for  by  each  globule  being 
an  aborted  scale ;  there  could  not  be  enough  aborted  scales  to 
furnish  so  much  mucus  so  full  of  globules.  I  believe,  therefore, 
that  it  grows  on  the  surface  by  their  budding  and  splitting  in 
continuous  succession. 


eO  THE  FORMATION  OF  MUCUS  AND  PUS. 

If  you  compare  pus  which  has  been  some  time  accumulating 
on  the  surface  of  a  mucous  membrane  with  that  which  is  being 
freshly  formed,  you  will  remark  a  decided  difference  in  the 
globules  they  contain.  Take  some  accessible  mucous  surface — 
the  eye,  or  the  vagina,  for  example — thickly  covered  with  opaque 
secretion,  and  you  will  find  the  globules  nearly  all  of  a  size, 
even  and  spherical.  Then  wash  it  clean  with  cold  water,  and 
examine  the  first-formed  secretion:  the  globules  are  of  all  sizes 
and  of  irregular  shapes,  oval,  bulging,  budding,  with  or  without 
nuclei.  This  seems  to  indicate  a  general  change  of  form  by 
time — a  certain  completion  of  creation  in  that  which  has  been 
longest  farmed. 

When  we  see,  as  I  have  described,  the  globules  of  mucus  bud- 
ding, dividing,  and  subdividing  in  active  haste — new  foci  of  in- 
dependent vitality  generated  and  multiplying  even  when  separated 
from  the  body — it  might  appear  that  a  local  increase  of  life  was 
being  exhibited.  Certainly  a  greater  bulk  of  living  substance  is 
formed  by  a  membrane  secreting  mucus  or  pus,  than  is  the  case 
in  the  healthy  state;  for  the  secretion  outweighs  by  a  hundred- 
fold the  daily  quantity  of  epithelium  which  its  original  material 
was  destined  to  make.  But  what  sort  of  degree  of  life  is  ex- 
hibited by  this  secretion?  Is  rapidity  of  multiplication  to  be 
looked  upon  as  evidence  for  or  against  force  of  vitality?  Against 
it,  I  think.  The  lower  we  go  in  the  scale  of  creation,  the  more 
quickly  and  the  more  copiously  do  the  living  forms  representing 
the  various  classes  reproduce  their  kind.  The  less  functions  and 
force  and  intensity  of  existence  they  have,  the  more  prominent 
becomes  reproduction  as  the  main  object  of  their  being  created. 
This  seems  to  be  the  universal  rule,  to  be  traced  all  through 
living  beings  till  we  get  down  to  the  Amoeba  and  the  mould,  in 
which  no  trace  of  a  function  can  be  detected  beyond  the  multi- 
plication of  their  simple  substance. 

Here,  indeed,  it  becomes  difficult  to  draw  the  line  between 
organic  and  inorganic.  Instead  of  being  in  contrast  and  in  con- 
flict with  the  physical  force  of  inanimate  nature,  vitality  seems 
to  obey  laws  which  closely  resemble  them.  The  main  point  of 
distinction  seems  to  be  the  growing  from  a  center  outward  of 


THE  FORMATION  OF  MUCUS  AND  PUS.  61 

organic,  and  the  ao;orres;ation  towards  the  center  of  inororanic, 
individuals. 

When  organic  matter  destined  to  form  part  of  an  animal  has 
attained  the  end  of  so  becoming  a  member  of  a  consistent  whole, 
it  ceases  to  multiply  itself.  Cells  do  not  normally  go  on  splitting 
up  and  producing  cells  similar  to  themselves  in  situ.  The  highest 
development  of  their  vitality  is  ceasing  to  exist  as  growing  matter. 
A  fully-formed  epithelium  scale  does  not  produce  another  scale, 
nor  the  nucleus  of  a  muscular  fiber  another  nucleus.  The  reten- 
tion of  reproductive  force  is  an  expression  of  the  lower  and  an 
exclusion  from  the  higher  functions  of  life. 

In  the  mucous  globule,  then,  we  find  organic  matter,  whose 
destination  was  the  formation  of  epithelium,  arrested  in  its 
development  when  it  has  attained  only  the  lowest  degree  of 
life — that  lowest  degree  of  life  being  the  function  of  repro- 
duction. 


LECTURE  IV. 

THE  FORMAT  I  ox  OF  MUCUS  AND  PUS. 

Mucous  globules  not  cells,  hut  nuclear  matter — The  representative 
of  the  cell  is  the  medium  in  lohich  they  float — It  is  therefore 
not  likely  to  retrograde  into  globules — Formation  of  pus  from 
mucus — How  does  pus  appear  on  the  surface? — Observations 
of  several  observers — Passage  of  globules  through  ejjithelium — 
Pus-globules  not  descendants  of  epithelial  cells,  but  jyarasitia 
formations  inside  t.h,em — Epithelium  semi-fluid — Breach  of 
epithelium  in  some  cases — Grroivth  of  pus. 

[Second  Lumleian  Lecture  at  the  College  of  Physicians, 
Lent,  1863.) 

I  DESCRIBED  in  my  last  lecture  the  mucous  globules  forming 
nuclei  in  its  center,  and  these  nuclei  splitting  up  into  two  or 
more,  subdividing  and  separating  the  Avhole  globule  into  several. 
From  this  it  has  been  inferred  that  it  is  in  this  way  that  the 
globules  grow — tliat  they  are,  in  fact,  cells  which  multiply  by 
subdivision.  But  I  described  also  the  formation  of  buds  at  the 
side  of  the  globules.  These  buds  commence  by  the  granules  of 
which  the  mass  of  the  globules  consists  becoming  gradually  more 
visible  and  distinct,  and  forming  centers  of  growth  distinct  and 
separated  by  a  conspicuous  interval  from  the  central  nuclei. 
They  are  not  derivatives  from  the  central  nuclei,  but  new  start- 
ing-points of  growth.  This  is  important,  because  it  takes  the 
globules  put  of  the  category  of  cells.  In  a  fully-formed  cell  it  is 
only  the  nucleus,  and  not  the  transparent  area  of  formed  matter, 
which  grows ;  whereas  here  the  whole  substance  grows  and  origin- 
ates growth.  The  globules  are,  in  fact,  nuclei.  Or  we  may 
more  properly  call  them  "nuclear  matter;"  for  a  nucleus  must 


THE  FORMATION  OF  MUCUS  AND  PUS.  63 

be  a  necleus  of  something,  whereas  these  are  nuclei  of  nothing. 
Nuclear  matter  is  that  which  is  fitted  to  be  the  nucleus  of  some- 
thing, unless  arrested  in  its  development — in  other  words,  organic 
living  matter  in  a  condition  to  grow  and  multiply.  A  confirm- 
ation of  this  occurs  in  a  drawing  by  Dr.  Beale.  When  tissues 
are  steeped  in  a  weak  solution  of  carmine,  the  only  parts  which 
receive  a  permanent  stain  are  the  nuclei,  or  young  growing 
matter  in  them.  Now,  of  the  mucous  globules  the  whole  sub- 
stance receives  a  permanent  stain,  as  is  shown  in  the  drawing 
here  exhibited.  It  appears  therefore  to  be  wholly  formed  of 
nuclear  or  growing  matter. 

It  may  be  remarked  that  the  mucin,  or  transparent  fluid 
medium  in  which  the  globules  float,  does  not  receive  so  marked 
and  so  permanent  a  stain  from  the  carmine;  and  this  appears  a 
very  fair  argument  for  considering  it  as  the  formed  substance 
of  which  the  globules  are  the  nuclei — a  sort  of  common  trans- 
parent area,  a  common  cell-wall  to  numerous  nuclei ;  just  as 
coral  is  the  common  skeleton  to  millions  of  coral  insects.  Each 
perfect  epithelial  scale,  each  nucleus,  has  its  own  formed  sub- 
stance constituting  its  own  cell-wall ;  in  the  lower  grade  of  life 
represented  by  mucus  there  is  a  less  perfect  common  formed 
substance,  constituting  a  common  cell-wall. 

Now,  if  the  mucin,  or  transparent  medium  in  Avhich  the 
globules  and  granules  float,  stand  in  the  place  of  fully-formed 
organic  substance  or  cell,  it  will  not  retrograde  into  the  con- 
dition of  growing  substance.  Such  a  retrogression  does  not 
happen  in  cells.  In  an  epithelial  scale,  for  instance,  the  trans- 
parent area  does  not  become  nuclear  matter.  But  it  transmits 
the  nutriment  to  the  necleus  inward  through  its  substance  with- 
out being  destroyed.  On  this  supposition  the  formation  of  mucin 
will  be  the  highest  development  of  the  life  of  the  globule,  for  it 
answers  to  the  formation  of  tissue  from  nuclear  matter.  And 
in  that  case  we  should  expect  to  find  that  the  nearer  its  normal 
condition  the  morbid  secretion  can  be  collected,  the  more  of  this 
higher  state  of  life  it  would  exhibit,  and  that  the  further  from  its 
normal  condition  it  is,  the  less  there  would  be  of  the  formed 
matter.     Such  is  the  fact.     The  fluid  which  first  forms  on  an 


64  THE  FORMATION  OF  MUCUS  AND  PUS. 

inflamed  f^urface  contains  few  globules  and  much  stringy  trans- 
parent medium.  Its  nuclear  matter  has  so  far  departed  from 
life  that  it  cannot  form  separate  cells,  but  only  an  imperfect 
common  area.  But  as  the  inflammation  goes  on,  this  power  is 
still  more  and  more  lost;  the  nuclear  matter  cannot  form  the 
mucin,  it  can  only  multiply ;  and  hence  the  stringiness  of  the 
mucus  disappears,  and  it  becomes  what  Ave  know  by  the  name 
of  "  pus."  As  far  as  the  morbid  matter  itself  is  concerned,  pus 
indicates  in  it  a  further  deficiency  of  vitality  than  mucus — a 
deficiency  of  vitality  shown  first  in  its  internal  self-multiplica- 
tion, and  secondly  in  its  non-production  of  mucin. 

The  question  naturally  arises  as  to  how  these  products  of 
arrested  vitality  make  their  way  to  the  surface  of  the  mucous 
membrane  where  we  find  them.  The  pabulum  whence  they  are 
developed  lies  on  the  inner  side  of  the  epithelium,  whereas  we 
find  them  quite  uncovered.  The  first  explanation  that  occurs 
•would  be  that  the  epithelium  is  destroyed,  and  that  they  are 
in  the  first  place  the  debris  of  the  dissolution,  united  to  that 
which  would  normally  go  to  form  it.  This  would,  in  fact,  be 
a  modification  of  the  old  idea,  that  pyogenesis  was  a  kind  of 
ulceration,  and  involved  a  certain  solution  of  continuity  in  a 
tissue.  Indeed,  it  would  amplify  the  idea,  for  it  would  extend 
its  application  to  mucus  as  well.  To  this  idea  Professor  Virchow 
seems  to  incline  in  the  edition  of  his  "Cellular  Pathology"  pub- 
lished in  1858  (p.  395),  where  he  represents  the  formation 
indeed  of  the  mucus  and  pus-globules  to  take  place  in  the 
lower  layers  of  the  epithelium,  but  to  be  mixed  with  and  to 
have  their  bulk  added  to  by  the  outer  layers  which  they  push 
off". 

Since  then,  however,  several  observers  have  found  that  the 
most  intense  catarrhal  condition  of  mucous  membranes  may 
exist  without  any  loss  of  the  superficial  epithelium.  Even  in 
that  most  destructive  state  commonly  known  as  diphtheritic 
inflammation,  where  fibrin  is  thrown  out  with  the  pus,  the 
epithelium  may  be  perfect.  Dr.  Sanderson  has  kindly  lent  me 
some  notes  he  made  of  the  autopsy  of  a  child  who  died  at  St. 
Mary's  Hospital  of  diphtheric  angina,  in  whose  larynx  this  fact 


THE  FORMATION  OF  MUCUS  AND  PUS.  65 

was  very  clearly  seen.  The  Avliole  interior  of  the  organ  was 
lined  with  a  firm,  closely  adherent  false  membrane.  When  that 
was  detached,  portions  of  flabby  concretion  still  remained,  which 
could  be  washed  oifwith  a  stream  of  water.  "On  examining 
the  surface,"  says  Dr.  Sanderson,  "after  much  wasliing,  it  was 
found  to  be  entire.  It  exhibits  to  the  naked  eye,  indeed,  marked 
inequalities  of  appearance,  as  if  eroded;  but  these  must  be  de- 
pendent on  the  adhesion  of  minute  particles  of  concretion;  for, 
on  makir)g  snips  of  the  surface  with  sharp  scissors  at  those  parts 
where  the  eroded  appearance  was  most  obvious — viz.,  on  the 
upper  surface  of  the  epiglottis,  the  epithelium  was  found  to  be 
entire.  The  only  exception  was  at  the  upper  margin  of  the 
ventricles,  where  the  epithelium  was  adherent  only  here  and 
there  ;  but  there  was  no  trace  of  thickening  or  alteration  of  the 
basis-membrane,  which  exhibited  its  normal  appearance."* 

Forsterj"  has  also  carefully  examined,  by  both  horizontal  and 
perpendicular  section,  the  epithelium  of  mucous  membranes  in 
a  state  of  purulent  catarrh,  and  has  found  in  it  either  no  change 
or  very  unimportant  change  from  the  normal  state. 

The  globules,  then,  or  the  material  of  the  globules,  must  some- 
how be  passed  through  the  epithelium.  Dr.  Buhl,  of  Munich, 
has  lately  detected  it  in  transitu,  and  drawn  figures  of  it  on 
the  road.  The  case  on  which  his  observations  were  made  was 
one  particularly  well  suited  for  the  purpose.  The  patient  had 
died  of  pyemic  inflammation  of  the  portal  vein  and  of  the  bile- 
ducts  of  the  liver.  Now,  the  epithelium  of  the  bile-ducts  pre- 
sents a  very  marked  character;  its  cylindrical  bodies  exhibit 
an  unmistakable  shape.  So  obvious  is  this  shape  that  it  can  be 
detected  even  when  considerably  distorted ;  and  therefore  he  was 
able  to  trace  the  epithelium  scale,  modified  by  what  he  ration- 
ally enough  concludes  to  be  the  presence  in  it  of  pus-globules. 
This  is  clearly  exhibited  in  his  sketches  of  the  various  forms 
or  stages  of  altered  epithelium  as  he  saw  it  floating  loose  in  the 
fluid   pus  or  massed    into  clots.      First,  he  shows   the   normal 

*  Private  notes  of  Dr.  Sanderson. 

f  Communication  from  the  Wiizhurg  Institute  of  Pliysiology  and  Anatomy. 
'  Wiiizburger  Med.  Zeitechrift,"  bd.  i,  j)art  2. 


6Q 


THE  FORMATION  OF  MUCUS  AND  PUS. 


epithelium  cylinder,  as  a  medium  of  comparison,  and  of  these 
there  were  great  quantities.  Then  come  a  number  of  bodies 
■which  we  can  recognize,  when  they  are  here  placed  in  a  row,  as 
perversions  of  the  cylinder,  gradually  increasing  in  rotundity 
and  receding  in  likeness  ;  but  Avhich  in  their  extreme  of  dis- 
similarity would  not  be  seen  to  have  any  connection  with  it 
except  by  a  previous  knowledge  of  the  fact. 


M 


(After  Buhl.) 

The  majority  of  the  enlarged  cells  were  filled  with  oil-granules. 
Others,  in  which  the  fat  was  accumulated  to  a  smaller  amount, 
contained  from  two  to  ten  rounded  bodies  exactly  like  the  free 
pus-globules  surrounding  them — so  like,  that  hardly  any  doubt 
could  be  entertained  that  they  were  cells  pregnant  with  pus- 
globules.  As  a  rule,  the  group  of  pus  globules  lay  close  to  the 
thick  end  of  the  cylinder;  but  often  between  the  thick  end  and 
the  groups  of  pus-globules  there  was  to  be  seen  a  degree  of  con- 
striction, making  the  cell  bottle-shaped.  Sometimes  the  tail  of 
the  cell  was  obliterated  or  torn  oft",  when  it  was  almost  globular, 
but  even  then  capable  of  recognition. 

In  cells  where  there  were  only  two  or  three  globules  the 
nucleus  remained  distinctly  visible  and  perfect.  In  others  the 
granular  globules  seemed  to  be  dividing  and  splitting  up  into 
four  or  six,  the  original  nucleus  of  the  cylinder  still  remaining 
visible.  So  that  pus-globules  evidently  do  not  of  necessity  take 
their  rise  in  the  degeneration  of  nuclei  of  existing  tissue. 

In  other  examples,  again,  the  cell-contents  seem  entirely  to 


THE  FORMATION  OF  MUCUS  AND  PUS.  67 

have  degenerated  into  fatty  molecules,  whether  from  the  growth 
of  the  globules  just  described  or  from  other  causes,  and  in  them 
the  nucleus  had  degenerated  along  with  the  rest  of  the  cell. 

I  have  noticed  in  the  epithelial  scales  from  the  vagina,  in 
cases  of  purulent  discharge,  a  somewhat  similar  repletion  with 
granular  matter  without  alteration  of  the  nucleus.  And  mixed 
with  them  there  were  also  large  round  granular  corpuscles,  which 
had  the  appearance  of  containing  pus-globules,  and  which  might 
have  been  degenerated  epithelial  scales.  But  scaly  epithelium 
has  not  such  a  definitely  marked  form  as  the  cylindrical  variety, 
and  it  is  difficult  to  identify  it  in  a  state  of  transmutation. 

Remak*  has  also  found  in  the  pus  from  inflamed  bladder 
large  cells  which  he  thought  he  identified  as  the  epithelium  from 
the  fundus  vesicae.  These  contained  from  six  to  fifteen  globules, 
entirely  filling  up  the  interior,  and  in  every  respect  like  mucus- 
corpuscles.  But  he  does  not  trace  a  series  of  transitional 
forms. 

It  will  be  seen  by  these  observations  that  the  pus-corpuscles 
are  not  so  much  descendants  of  the  epithelial  cells  as  what  may 
be  called  parasitic  formations  within  them.  They  are  parasites 
inside  the  epithelial  cells,  capable  of  increase  by  propagation 
within  the  tissue,  just  as  on  the  surface  the  mucous  globules 
were  shown  as  parasites  capable  of  increase  by  propagation 
without  the  tissue.  And  they  grow  quite  independent  of  the 
true  nucleus  of  the  cell,  and  are  not  derived  from  it.  Thus  the 
nuclear  material  may  pass  through  the  substance  of  the  epithelial 
coat  of  mucous  membrane  without  destroying  it,  and  not  only 
be  itself  unaltered,  but  may  increase  in  quantity  during  the 
progress.  This  is  one  way  in  which  the  pus-material  may  reach 
the  surface,  and  explains  those  cases  in  which  the  epithelium  is 
quite  uninjured. 

We  find  these  fluid  or  semi-fluid  properties  exhibited  by  epi- 
thelial cells  in  their  daily  duty  of  absorption.  Fat,  from  its 
highly  refractive  powers,  can  easily  be  traced,  though  a  fluid, 
by  the  microscope ;  and  fat  in  globules  can  be  seen  passing 
through  the  substance  of  the  epithelial  cells  of  the  intestines 

*  Virchow,  "  Archiv,"  bd.  xx,  p.  198. 


68 


THE  FORMATION  OF  MUCUS  AND  PUS. 


during  their  active  state.  This  is  well  shown  in  some  recent 
drawings,  made  by  Balogh,*  of  intestinal  epithelium  during  the 
ingestion  of  fat ;  the  whole  thickness,  not  a  central  tube,  but  the 
whole  thickness  of  the  cell,  is  seen  permeated  by  it,  and  allow- 
ing it  free  passage.  The  physiological  passage  of  fat  globules 
inwards  may  reconcile  us  to  the  idea  of  the  pathological  passage 
of  pus  outwards. 

But  Professor  Henle  well  says :  "If  they  are  sometimes  formed 
in  the  interior  of  a  cell  saturated  with  their  material,  this  fact 
does  not  exclude  the  possibility  that  just  in  the  same  way  they 
may  sometimes  be  developed  from  the  same  plasma  beneath  the 
cells."  In  such  case  they  would  be  projected  on  to  the  surface 
between  the  separated  epithelium  cells. 

This  other  mode  of  growth  and  attaining  the  surface  is 
strikingly  shown  in  a  drawing  by  Dr.  Edward  Rindfleisch,  of 
Breslau,t  which  exhibits  in  section  the  nictitating  membrane  of 
a  frog  affected  with  a  partial  catarrh  of  the  eyes.  Fig.  3  is 
the  normal  state,  where  the  me'iuhrana  propria  (as  Professor 
Henle  calls  it)  is  seen  as  a  moderately  transparent  layer,  with 
Fig.  3.  Fig.  4. 

@ 


After  Rindfleisch. 

its  delicate  areolar-tissue-corpuscles,  and  the  epithelium  as  two 
parallel  rows  of  equal-sized  cells.  In  Fig.  4  the  pathological 
condition  is  represented ;  the  pavement  of  epithelium  is  thrown 
up  and  separted  by  nucleated  pus  or  mucus-globules,  which 
are  seen  to  proceed  from  the  membrane  beneath.  And  the 
substance  of  this  membrane  appears  to  be  saturated  and  ren- 
dered opaque  by  what  must  be  an  earlier  condition  of  the  same 
bodies. 

*  Moleschott,  "  UntfTsuchungeii  zur  Naturlelire, "  bd.  vii,  6tes  heft, 
f  Virchovv,  "  Arcbiv,"  bd.  xxi,  plate  viii. 


THE  FORMATION  OF  MUCUS  AND  PUS.  69 

These  observations  seem  to  show  that  the  pus-  or  mucus- 
globule  on  mucous  membranes  is  the  material  of  young  or  re- 
novated epithelial  cells,  arrested  in  its  development  at  the 
earliest  dawn  of  life,  before  it  has  assumed  the  form  of  a  cell, 
when  it  is  almost  as  unlike  its  destined  final  form  as  an  egg  is 
to  a  chicken.  They  seem  to  show  that  in  this  state  it  may  be 
thrown  directly  off  by  the  epithelium  being  broken,  or  it  may 
pass  into  the  substance  of  the  epithelium.  In  either  case  it  does 
not  part  with  the  low  degree  of  life  it  has  acquired ;  but  neither 
does  it  acquire  a  higher  degree;  it  goes  on  propagating,  but 
nothing  more. 

Both  Buhl's  and  Rindfleisch's  observations  seem  also  to  prove 
that  pus-globules  are  not  produced,  or  at  least  not  produced 
only,  by  the  degeneration  of  existing  cells;  they  are  not  tissue 
retrograding  into  a  lower  form  of  life  like  fatty,  amyloid,  and 
similar  morbid  matter.  Buhl's  drawings  especially  exhibit  the 
nucleus  of  the  epithelial  cell  intact  along  with  the  newly- 
formed  pus-globule.  They  differ,  however,  in  one  particular, 
that  whereas  according  to  Buhl  the  first  pus-globule  produced 
free  in  the  cell  increases  itself  by  division,  Rindfleisch  assumes 
a  splitting  up  of  the  whole  contents  of  the  cell  according  to  the 
analogy  of  the  egg-3^elk.  As  Buhl's  observations  are  made  upon 
epithelium  alone  and  Rindfleisch's  upon  areolar  tissue  also,  and 
in  one  case  the  epithelium  remained  perfect  and  in  the  other 
was  broken  up,  I  can  see  no  inconsistency  in  allowing  both  to 
be  correct,  and  to  represent  the  different  behaviour  of  growing 
matter  under  different  circumstances. 

A  very  ingenious  locality  has  been  selected  by  Junge*  for  the 
investigation  of  the  growth  of  pus — viz.,  the  tunic  of  the  aque- 
ous humor  in  the  eye.  He  caused  inflammation  by  the  appli- 
cation of  a  hot  wire  to  the  cornea  of  an  animal,  and  was  thus 
able  to  see  what  went  on  in  the  deeper  parts  of  the  eye  without 
exposing  the  affected  tissue  to  the  air  or  any  other  extraneous 
agency.     He  was  thus  able  to  see  the  activ'e  growth  of  globules 

*  "  Uber  Eiterbildung,"  &c.:  "  Archiv  fiir  Path.  Anatomic  und  Pliysiologie," 
bd.  jxii,  heft  1,  2,  p.  193. 


70  THE  FORMATION  OF  MUCUS  AND  PUS. 

by  division  and  subdivision  so  far  as  the  formation  of  large 
masses. 

As  tlio  secretion  on  the  surface  of  mucous  membranes  becomes 
more  opaque  or  "purulent,"  so  the  globules  are  more  and  more 
regular  in  size,  rounder,  and  more  like  one  another.  In  trans- 
parent mucus  most  of  them  are  oval,  with  nuclei  indistinct 
and  various  in  number,  -while  there  are  often  lumps  on  their 
sides  distorting  the  form.  In  creamy  pus  they  are  nearly  all 
of  a  size,  and  present  two  or  three  well-marked  nuclei.  This 
is  easily  accounted  for,  if  we  admit  that  they  are  multiplied  on 
the  surface  of  the  membrane.  When  first  formed,  they  appear 
under  violent  and  varying  circumstances,  diiferent  in  degree 
every  moment,  and  therefore  are  different  in  form;  but  when 
once  separated  they  may  go  on  multiplying  under  favor  of 
nutriment  and  heat  for  several  generations.  Thus,  like  wild 
races  of  animals,  they  lose  individual  differences,  and  become 
more  and  more  similar  and  uniform  in  characteristics. 

The  formation  of  pus  in  deep  seated  parts  is,  of  course,  not 
so  easy  to  trace  as  on  surfaces,  and  experimenters  seem  deterred 
by  the  difficvilty  of  the  subject.  In  all  tissues  where  pus  is 
found,  its  optical  characteristics  are  the  same  as  the  fully  formed 
pus  of  mucous  membranes:  it  presents  globules  all  nearly  of  the 
same  size,  and  with  a  pretty  even  amount  of  nuclei.  This  is  its 
complete  condition  ;  but  what  it  is  like  immediately  on  its  sepa- 
ration Ave  do  not  know.  We  cannot  trace  it  throuorh  a  stao;e  analo- 
gous  to  mucus. 

Of  its  previous  condition,  however,  we  may  form  a  shrewd 
conjecture.  The  same  elementary  substance  which  appears  on, 
or  rather  in,  integumentary  tissues  as  the  common  material  of 
the  various  kinds  of  epithelium,  appears  also  as  granular  nuclei 
in  other  tissues — in  the  ganglia  of  nerves,  in  the  brain,  in  the 
parenchyma  of  the  liver,  in  the  spleen,  thyroid  and  thymus,  &c. 
The  same  bodies  occur  also  in  the  blood,  where  they  have  been 
termed  "chyle-corpuscles"  and  "white  cells."  They  are  found 
in  largest  quantities  in  the  most  recently  formed,  most  quickly 
growing,  and  most  actively  renewed  component  parts  of  the 
animal  frame.     In  short,  the  most  rational  interpretation  of  this 


THE  FORMATION  OF  MUCUS  AND  PUS.  71 

form  of  organic  matter  is  that  which  represents  it  as  the  common 
material  of  all  tissues  in  its  earliest  state  of  elementary  life.  And 
as  that  which  was  to  have  formed  epithelium  is  cast  off  as  the 
basis  of  the  mucus  and  pus-globule,  so  that  which  was  to  have 
formed  hepatic  parenchyma,  nerve,  or  areolar  tissue  becomes 
pus,  perhaps  through  some  unsuspected  transitional  stage. 

In  this  account  of  organic  forms  in  pus  and  mucus  I  have 
endeavored  to  harmonize  the  contributions  of  several  observers. 
I  have  done  this  mainly  by  omitting  points  of  observation  and 
deductions  in  which  they  differ  from  one  another,  and  putting 
together  those  on  which  they  agree.  Their  harmony  has  also 
been  much  assisted  by  translating  into  a  common  language  the 
various  terms  in  which  they  express  the  laws  of  life  which  their 
observations  appear  to  exhibit. 


LECTURE   V. 

THE   FORMATION   OF   MUCUS   AND   PUS. 

Mucus  and  pus  compared — Grades  of  loss  of  vitality  in  mucous 
membranes — Exemplification  of  these  grades  in  smalljjox  pus- 
tules— Practical  deductions  from  the  various  points  commented 
on  in  the  three  lectiires. 

( Third  Lumleian  Lecture  at  the  College  of  Physicians,  Lent,  1863.) 

In  respect  of  the  vitalized  forms  which  they  exhibit,  we  may 
consider  pus  and  mucus  as  identical ;  the  pus  globule  being  merely 
the  descendant  more  or  less  remote  of  the  mucus-globule,  and 
both  retaining  only  that  low  degree  of  life  which  they  originally 
■derived  from  the  body.  The  physical  differences  between  the 
two  depend  seemingly  upon  the  medium  in  which  these  vitalized 
forms  are  suspended.  Neither  in  pus  nor  mucus  are  the  con- 
tents of  this  medium  constant  in  their  proportion  to  one  another; 
no  two  analyses  of  pus  or  mucus  are  ever  the  same. 

Indubitable  pus  and  indubitable  mucus  may  be  clearly  defined 
;as  the  two  ends  of  a  scale,  between  which  there  are  innumerable 
gradations.  The  most  transparent,  stringiest,  and  least  globular 
mucus  consists  principally  of  a  peculiar  animal  matter,  which  is 
not  albumen,  though  it  closely  resembles  it.  It  is  not  coagulable 
by  heat,  and  it  contains  more  oxygen  on  ultimate  analysis  than 
albumen  does.  Sulphur  also  appears  not  to  be  one  of  its  con- 
stituents. Until  it  can  be  found  reducible  to  be  considered  a 
compound  of  some  known  intermediate  substances,  it  is  tempo- 
rarily called  "mucin."  This  word  simply  means  mucus  divested 
•of  those  contents  which  are  capable  of  another  nomenclature  and 
physical  separation — as,  for  instance,  epithelium-scales,  blood, 
the  ammonia  of  decomposition,  &c.    The  analyses  are  well  known, 


THE  FORMATION  OF  MUCUS  AND  PUS.  73 

being  reprinted  in  every  work  of  physiological  chemistry,  but 
shed  little  light,  for  the  obvious  reason  that  the  substance  ana- 
lyzed is  hardly  ever  twice  the  same. 

Pus,  on  the  other  hand,  contains  a  large  quantity  of  albumen, 
and  a  large  quantity  of  fat.  A  modification  in  the  mode  of  the 
loss  of  health  is  characterized  by  the  presence  of  fibrin,  and  cer- 
tain forms  of  defective  vitality  by  casein  being  also  found.  The 
inorganic  constituents  of  both  see?n  to  be  the  same  as  those  of 
blood-serum  with  some  of  its  water  lost.  Our  diagnosis,  then, 
of  the  morbid  secretions  of  the  mucous  membranes  should  be  noc 
absolute — not  that  such  and  such  a  specimen  is  pus  or  is  mucus — 
but  comparative,  that  it  is  more  or  less  purulent,  according  as  it 
exhibits  a  greater  or  smaller  quantity  of  albumen ;  a  fact  easily 
ascertained  by  the  degree  of  its  coagulation  by  heat  when  diluted 
with  water.  And  this  is  thoroughly  practical  and  important,  for 
it  indicates  the  degree  of  loss  of  local  vitality  in  the  secreting 
membrane.  Equally  practical  also  and  important  is  the  obser- 
vation of  the  presence  of  fibrin  and  its  amount.  In  large  and 
overwhelming  quantities  we  are  familiar  with  it  as  occurring  in 
the  most  serious  deficiency  of  life  consistent  with  life  at  all  which 
we  find  in  mucous  membranes;  and  there  appears  even  in  minor 
cases  a  closer  connection  between  its  amount  and  the  degree  of 
deficient  vitality  or  inflammation.  During  a  severe  cold  in  the 
head  minute  clots  of  spontaneously  coagulating  fibrin  may  be 
found  in  the  secretion  of  the  Schneiderian  membrane,  which, 
existing  in  large  quantities,  foim  the  false  membranes  indicative 
of  the  serious  poisoning  of  the  system  in  diphtheria  and  croup. 

The  phenomena  we  see  on  the  mucous  membranes  are  a  ques- 
tion of  degree  rather  than  of  essential  difi"erence. 

Loss  of  vitality,  as  shown  in  mucous  membranes,  seems  to  be 
exhibited  in  the  following  degrees: 

First  there  is  an  arrest  of  function.  For  example,  from  the 
impression  of  cold  the  Schneiderian  membrane  is  temporarily 
deprived  of  its  endosmotic  force;  it  ceases  to  absorb  the  water 
which  is  condensed  on  its  surface  from  the  breath,  and  that  water 
drips  from  the  nostrils.  Or  the  stomach  or  intestines,  from 
mental  or  physical  causes,  are  deprived  of  their  power  of  absorb- 


74  THE  FORMATION  OF  MUCUS  AND  PUS. 

ing  and  digesting  the  fluid  matters  presented  to  them,  and  par- 
tially first  excreted  from  them ;  and  these  fluids  may  pass  away 
by  diarrhoea.  Or  the  skin  is  chilled,  and  shows  its  deficient 
vitality  chiefly  in  the  deficiency  of  its  most  prominent  function ; 
though  it  feels  painfully,  it  cannot  feel  so  delicately  as  it  ought. 
In  a  vigorous  person  full  life  is  soon  regained:  the  nose  recovers 
its  natural  degree  of  dryness ;  the  intestines  absorb  again  before 
the  fluids  have  passed  from  the  body,  and  the  temporary  indi- 
gestion does  not  arrive  at  diarrhoea :  the  skin  recovers  its  feeling 
after  a  temporary  painfulness.  But  we  know  that  our  invalid 
patients,  whose  vitality  is  low,  are  not  so  easily  reinstated. 
Catarrh  of  various  parts  quickly  and  readily  follows  the  action 
of  physical  agents.  It  is  probable  that  in  this  least  degree  of 
injury  the  capillaries  are  contracted  in  area,  and  consequently 
the  rapidity  of  their  stream  increased,  by  the  action  of  the 
nerves.  This  phenomenon  is  wanting  where  the  injury  is 
greater;  in  experiments  upon  animals  the  microscope  does  not 
detect  it,  if  the  reagent  applied  is  powerful. 

2.  A  greater  degree  of  injury  is  accompanied  by  a  loss  of  elas- 
ticity in  the  capillaries.  Their  dilatation,  and  the  consequent 
retention  and  stagnation  of  the  blood  in  them,  is  familiar  to  us 
all,  in  both  the  living  and  dead  subject,  as  '•'■  inflammatory  con- 
gestion.'' 

3.  This  stagnation  may  be  in  isolated  spots  complete;  the 
blood-disks  adhere  together  in  rolls,  as  when  removed  from  the 
body,*  and  block  up  the  passage.  Thus  the  arterial  wave  is 
obstructed  in  its  course,  and  like  an  ocean  swell  shattered  against 
a  shore  of  rocks,  becomes  more  evident  to  the  senses  as  the  well- 
known  '■'■  throbbing .''  It  is  shortened  and  sharpened,  but  there 
is  no  evidence  that  it  is  strengthened;  indeed,  the  analogy  I 
have  cited,  and  the  general  fact  of  weakness  being  accompanied 
by  quickened  pulse,  would  seem  to  show  that  it  is  diminished  in 
propelling  force. 

*  It  is  not  necessary  here  to  go  into  the  question,  so  abl_y  treated  by  Mr. 
Lister,  as  to  the  first  origin  of  this  evidence  of  death;  whether  the  blood-disks 
adhere  in  consequenfe  of  their  own  idiopathic  death,  or  in  consequence  of  the 
withdrawal  of  the  influence  of  the  tissues,  which  normally  keep  them  from  ad- 
hering:. 


THE  FORMATION  OF  MUCUS  AND  PUS.  75 

In  the  meantime  there  is  an  accumulation  of  that  constituent 
of  the  blood  which  most  resembles  in  appearance  the  element  of 
young  growing  tissue — the  colorless  hlood-corpuscles.  The  blood 
is  dark,  indeed,  to  the  naked  eye,  but  under  the  microscope  is 
seen  to  be  made  dark  by  being  filled  with  these  pale  bodies,  pos- 
sessing a  high  refractive  power. 

The  loss  of  elasticity  in  the  coats  of  the  capillaries  renders 
them  more  easily  permeable  by  the  contained  fluid.  Serum  is 
poured  out  into  the  neighboring  parenchyma,  and  joins  with  the 
swollen  capillaries  in  producing  ^'■stveUing.'"  The  loss  of  vitality 
in  the  blood-disks  maybe  so  complete  that  their  hiematin  is  dis- 
solved in  the  serum,  and  we  get  the  surrounding  parts  stained 
with  it — as  for  a  short  time  in  typhus  fever,  and  for  a  long  time 
in  syphilitic  eruptions.  Or  the  blood-vessels  may  completely 
lose  their  cohesion  and  be  ruptured,  allowing  of  haemorrhage. 
But  in  all  this  there  is  no  new  process,  nothing  which  is  not  a 
direct  deficiency  of  function. 

In  solid  structures  this  effusion  is  followed  by  an  endosraotie 
current  of  the  watery  part  back  again  into  the  circulation,  leav- 
ing behind  it  the  more  solid  and  coagulable  constituents.  On 
free  surfaces,  covered  only  by  soft  open  epithelium,  the  water 
and  salts  therein  dissolved  escape,  forming  the  fluid  of  the 
mucus.  The  elements  of  new  tissue,  being  there  very  copious  to 
supply  the  constant  demand  for  growth,  ooze  out  copiously  with 
the  serum,  and  constitute  the  mucous  globules.  They  are  wasted 
elements  of  new  growth,  not  themselves  a  new  creation,  or  evi- 
dences of  superadded  life. 

How  do  these  matters  get  through  the  coats  of  the  capillaries? 
There  cannot  be  holes  for  their  escape,  or  else  the  blood-disks, 
which  are  the  smaller  of  the  two,  would  escape  also.  Doubtless 
this  is  one  of  the  great  riddles  of  physiology.  But  the  art  of 
drawing  is  in  a  certain  degree  responsible  for  some  of  the  difii- 
culty  which  it  presents  to  our  minds.  When  Ave  have  no  means 
of  correctirg'  by  our  other  senses  impressions  made  on  the  eye, 
we  are  too  apt  to  consider  everything  with  an  outline  as  equally 
solid.  The  necessarily  hard  outlines  of  the  engraver  express  to 
us  forms  which  may,  for  all  the  paper  shows,  be  spheres  of  cast 


76  THE  FORMATION  OF  MUCUS  AND  PUS. 

iron,  whereas  in  truth  they  are  as  delicate  as  aerial  clouds.  "Why 
may  they  not  pass  through  tissues,  mutually  dissolving  and  dis- 
solved by  the  materials  of  those  tissues  ?  Just  as  we  see  a  stratum 
of  fleecy  cloud  among  mountains,  or  in  Turner's  pictures,  disap- 
pear when  it  comes  to  a  stratum  of  warm  air,  and  reappear  in 
the  same  form  when  it  emerges  on  the  other  side.  To  get  just 
ideas  of  nature,  we  must  look  upon  solidity  as  a  comparative, 
not  as  an  absolute,  quality. 

4.  In  a  higher  degree  of  deficient  vitality  the  serum  contains 
albumen  and  fat  also  exuded  with  it;  and  this  mixed  with  the 
multiplied  globules  constitute  the  fluid  we  call  "pus."  The 
albumen  and  fat  not  only  escape  on  free  surfaces,  but  saturate 
also  the  tissues  they  escape  through,  making  them  more  reten- 
tive of  water  than  would  otherwise  be  the  case.  Inflamed  cuticle 
takes  a  much  longer  period  to  dry  than  normal  cuticle.  Lan- 
ghans*  found  that  a  piece  of  healthy  rabbit-skin  was  crisp  in 
three  hours,  but  a  piece  of  the  same  skin  which  had  been  in- 
flamed during  life  took  twenty  hours  to  part  with  its  moisture 
to  the  same  extent.  It  appears  to  be  saturated  with  the  nutri- 
ment which  it  has  lost  the  power  of  employing  aright. 

5.  Pus,  formed  as  I  have  described,  is  a  soft  and  greasy  sem.i- 
liquid,  capable  of  shielding  from  foreign  influences  the  part  with 
which  it  lies  in  contact.  It  is  more  bland  and  less  liable  to  de- 
composition than  any  artificial  application;  for  perfectly  "laud- 
able" pus  laid  on  the  healthy  skin  causes  less  irritation  than 
even  water.  But  under  certain  circumstances  it  becomes  what 
we  term  ichorous;  and  then  it  is  corrosive,  poisonous,  and  de- 
structive to  the  neighboring  tissues.  Now,  this  cannot  arise 
simply  by  the  chemical  decomposition  of  the  pus  itself  in  conse- 
quence of  retention ;  because  in  a  good  many  cases  (as  in  cancrura 
oris,  for  example)  it  has  not  been  retained  so  long  as  usual,  but 
is  thrown  off"  ichorous  and  irritating  as  it  is  formed.  But  you 
may  observe  that  in  all  these  instances  of  ichorous  pus  there  is 
necrosis,  mortification,  ulceration,  or  some  other  form  of  actual 
loss  of  tissue.  Tissue  may  be  formed,  as  in  granulations,  but  it 
is  being  destroyed  at  the  same  time  with  abnormal  rapidity.     I 

*  "Zeitschrift  fur  Rat  Med.,"  R.  iii,  bd.  xii,  heft  2. 


THE  FORMATION  OF  MUCUS  AND  PUS.  77 

cannot  but  think,  therefore,  that  the  ichorous  nature  of  such 
pus  may  be  clue  to  its  saturation  with  the  organic  acids  which 
are  the  results  of  the  decomposition,  not  of  the  pus  itself,  but  of 
the  melting  tissues.  Wash  away  this  irritating  pus,  clean  the 
sore,  and  that  which  is  then  formed  often  is  quite  bland  and 
benignant.  As  pus  differs  from  mucus,  so  ichor  differs  from 
pus  in  the  nature  of  its  accidental  fluid  constituents. 

The  formation  of  ichorous  pus  exhibits  a  further  stage  of  loss 
of  vitality.  The  poisonous  part  of  it  seems  to  be  peculiarly 
soluble,  and  capable  of  uniting  with,  and  destroying  animal  tis- 
sues. Absorbed  into  the  blood,  it  naturally  destroys  the  vitality 
of  the  constituents  of  that  fluid,  causes  it  to  coagulate  in  localized 
spots,  and  thus  to  give  rise  to  the  congestions  and  abscesses  of 
pyiTeraia.  When  we  reflect  how  easily  ulcerations  may  arise  in 
mucous  membranes,  and  what  an  active  surface  they  offer  for 
absorption,  we  cannot  be  surprised  at  the  frequency  with  which 
pysemic  abscesses  follow  slight  injuries,  such  as  operations  on 
the  bladder,  crushing  of  calculi,  typhous  iniammation  of  the 
bowels — cases  which  seem  of  minor  moment,  but  which  certainly 
involve  solutions  of  continuity,  Avith  consequent  decomposition 
of  tissue  and  the  formation  of  ichor,  in  a  situation  very  open  to 
absorption. 

6.  The  formation  of  fibrinous  coats  on  mucous  membranes 
I  have  already  shown  not  necessarily  to  involve  destruction  of 
the  epithelium.  Is  the  loss  of  vitality  which  causes  it  to  exos- 
mose  through  tlie  capillaries  in  the  fibrin  itself  or  in  the  walls 
of  those  vessels?  Whichever  it  may  be,  such  an  exudation  cer- 
tainly is  evidence  of  a  great  deficiency  of  life;  and,  moreover, 
by  the  mechanical  impediment  it  throws  in  the  way  of  the  func- 
tions, usually  leads  to  further  deficiency. 

These  facts,  so  familiar  to  us  all  in  our  daily  work,  viewed 
thus  in  connection  with  one  another,  cannot  fail  to  impress  us 
with  the  feeling  that  the  seeming  activity  of  mucous  membranes 
in  diseases  is  in  truth  a  descending  scale  of  loss  of  vitality.  And 
this  feeling  must,  I  think,  have  great  weight  in  our  therapeutical 
dealings  with  those  diseases;  indeed,  I  cannot  imagine  anything 
of  more  practical  importance  to  physicians  and  their  patients. 
6 


78  THE  FORMATION  OF  MUCUS  AND  PUS. 

The  influence  of  physical  agents  on  mucous  membranes  which 
are  throwing  off  mucus  or  pus,  or  are  disposed  to  do  so,  is  very 
different  from  what  it  is  during  their  health.  A  degree  of  cold, 
which  is  borne  with  ease  by  them  when  in  full  vigor,  causes  a 
further  arrest  in  their  functions,  and  heat  is  equally  badly  borne. 
The  action  of  oxygen,  as  contained  in  atmospheric  air,  is  to  the 
healthy  tegumentary  tissues  invigorating  and  beneficial;  but 
when  their  vitality  is  lowered,  exposure  to  it  kills  them  still 
further,  and  may  even  alone  prove  fatal  to  the  patient,  as  we 
see  in  the  instance  of  extensive  burns. 

I  was  lately  much  struck  with  the  noxious  influence  of  atmos- 
pheric air  on  the  pyogenic  skin  in  a  case  of  confluent  smallpox. 
At  the  period  of  the  maturation  of  the  pocks,  when  just  pre- 
paring to  begin  drying  up,  they  presented  three  grades,  dis- 
tinguishable by  the  following  microscopic  differences  in  their 
contents.  In  one  sort  the  matter  was  of  the  consistence  of  thin 
lard,  white  and  opaque.  Examined  under  the  microscope,  it  w;is 
seen  to  consist  of  epidermic  scales,  many  of  normal  aspect,  but 
some  filled  w^ith  granular  matter  hiding  from  view  the  central 
nucleus.  In  another  sort  the  normal  scales  were  few,  the  granu- 
lar scales  equalling  them  in  number ;  but  more  numerous  than 
either  were  pus-globules  of  various  sizes  and  of  irregular  shapes, 
as  if  budding  on  several  sides.  In  a  third  sort,  taken  from  the 
very  confluent  parts  of  the  eruption,  there  was  nothing  to  be 
seen  in  general  but  regularly  formed  pus-globules  of  even  size, 
and  a  number  of  highly  refractive  globules  (of  fat)  among  them. 
The  fully  formed  pus  was  so  copious  that  it  overpowered  the 
debris  of  epidermis,  which  was  barely  visible.  These  three 
classes  of  microscopic  phenomena  represented  three  grades  of 
destruction  which  the  skin  had  undergone  from  the  effect  of  the 
variolous  poison.  In  the  first  the  epidermis  was  merely  de- 
stroyed, and  the  materials  for  renewal  were  available  for  a  new 
one.  In  the  second  to  a  slight  degree,  and  in  the  third  com- 
pletely, these  were  converted  into  pus  to  a  great  depth.  Con- 
sequently there  was  great  risk  of  permanent  destruction  of  the 
skin,  or  a  scar.  Now  I  found  that  the  grade  of  destruction  bore 
a  direct  ratio  to  the  exposure  of  the  various  parts  to  the  air. 


THE  FORMATION  OF  MUCUS  AND  PUS.  79 

The  most  favored  situations  Avere  the  thiglis,  abdomen,  and 
tongue,  where  the  pocks  of  the  first  or  less  injurious  kind  were 
very  numerous.  Next  came  the  legs  and  back,  and  tiien  the 
hands  and  forearms.  The  face  was  the  most  purulentlj  affected 
of  all.  The  back  (where  the  eruption  was  conlluent)  maintained 
its  comparative  immunity  in  spite  of  the  cuticle  being  much 
chafed  by  the  movements  of  the  sufferer.  You  will  notice  that 
the  most  affected  situations  are  those  which  are  most  exposed  to 
oxygen  and  evaporation,  which  are  life  to  the  healthy  skin,  but 
death  to  it  when  diseased. 

On  rational  grounds,  tlien,  I  think  the  practice  of  painting 
over  the  pocks  in  prominent  and  important  situations  with  col- 
lodion, caoutchouc,  or  gutta  percha  may  be  fairly  defended.  In 
this  way  we  do  all  we  can  to  secure  a  local  atmosphere  of  car- 
bonic acid — the  normal  atmosphere  of  intei-nal  tissues, — and  to 
prevent  the  loss  of  vitality  in  the  covered  parts. 

More  than  this,  I  think  we  should  be  led  to  consider  whether 
we  do  not  sometimes  err  in  applying  too  rigidly  the  theory  of 
the  universal  wholesomeness  of  fresh  air.  Fatal  cases  teach  us 
that  it  is  bad  for  inflamed  skins  ;  is  it  good  for  wounds  ?  is  it 
good  for  abscesses?  is  it  good  for  inflamed  lungs?  As  physi- 
cians we  have  most  to  do  with  the  latter  case ;  and  I  must  say  I 
find  that  few  things  contribute  to  the  ease  and  recovery  of  my 
patients  so  much  as  limiting  the  supply  of  oxygen  in  the  atmos- 
pheric air  by  saturating  it  with  w'atery  vapor.  I  refer  here  not 
only  to  pneumonia,  but  to  all  catarrhal  affections  of  the  breath- 
ing apparatus. 

The  stomach,  again,  is  much  benefited  by  carbonic  acid.  It 
naturally  contains  that  gas,  and  some  cases  of  deficient  diges- 
tion appear  to  arise  from  its  absence.  Atmospheric  air  swal- 
lowed with  the  food,  or  by  a  pernicious  habit,  produces  dyspepsia ; 
and  nothing  benefits  that  dyspepsia  so  much  as  solution  of  car- 
bonic acid  in  water.  Soda  water,  potash  water,  and  lithia 
water  derive  their  main  virtue  from  the  fl'xed  air  contained  in 
them. 

I  believe  that  the  only  way  in  which  carbonic  acid  is  employed 
in  surgery  is  under  the  form  of  yeast  poultices,  which  certainly 


80  THE  FORMATION  OF  MUCUS  AND  PUS. 

stay  the  progress  of  death  in  the  skin  quicker  than  most  appli- 
cations. Were  I  a  surgeon,  I  should  like  to  try  the  use  of  the 
gas  in  a  purer  form  as  a  healing  agent  for  wounds,  operative  or 
accidental. 

Such  an  atmosphere  of  carbonic  acid  is  to  a  certain  extent 
secured  to  sore  places  by  a  layer  of  pus  or  mucus,  Avhicli  is  satu- 
rated with  that  gas,  and  not  very  pervious  to  oxygen.  It  is  a 
great  defence  against  noxious  agencies,  and  I  think  we  are  wrong 
to  clear  it  away  more  than  is  necessary  to  comparative  cleanli- 
ness and  the  patients'  comfort.  We  know  how  much  lighter 
gonorrhoea  is  in  the  female  than  in  the  male,  and  one  reason 
appears  to  be  that  the  secretion  is  not  constantly  washed  off  the 
mucous  membrane  by  the  passage  of  the  urine.  Dirty  people 
seem  hardly  to  notice  the  existence  of  these  discharges  from  the 
mucous  membrane — they  come  and  go  of  their  own  accord  with- 
out causing  any  illness  ;  while,  on  the  other  hand,  cleanly  pa- 
tients are  martyrs  to  their  minor  virtue  and  to  their  sensitiveness, 
protracting  and  aggravating  disease  by  constantly  removing  the 
defence  which  pus  or  mucus  presents  against  oxygen  and  cold. 
Of  course  an  exception  must  be  made  of  cases  where  the  pus  is 
ichorous  and  poisonous  in  its  quality,  for  then  the  sooner  it  is 
removed  the  better  for  the  patient. 

On  the  principle  of  not  too  frequently  cleansing  away  mucous 
secretions,  I  should  attribute  greater  advantages  than  we  are  in 
the  habit  of  attributing  to  opiates  and  other  sedatives  in  those 
pulmonary  affections,  where  there  is  a  copious  bronchial  dis- 
charge. Their  obvious  and  immediate  effect  is  to  ease  the  cough; 
and  some  medical  men  are  in  the  habit  of  speaking  of  that  alle- 
viation as  if  it  were  merely  a  convenient  mask  to  conceal  the 
morbid  action  proceeding  on  uninterruptedly.  This  easing  of 
the  cough,  doubtless,  takes  place  through  the  pneumo-gastric 
nerve  being  rendered  less  sensitive  to  the  presence  of  the  abnor- 
mal secretion,  and  so  allowing  it  to  collect  in  larger  quantity 
before  it  is  expectorated.  So  that  I  cannot  but  think  this  col- 
lection in  larger  quantities  before  expectoration  is  beneficial  as  a 
defence  and  as  a  curative  measure. 

The  idea  which  I  have  tried  here  to  inculcate,  that  an  increase 


THE  FORMATION  OF  MUCUS  AND  PUS.  81 

in  the  quantity  of  living  tissues  is  by  no  means  an  evidence  of 
an  increase  of  their  life  or  of  their  powers  of  life — nay,  further, 
that  it  is  rather  an  evidence  of  deficient  life,  cannot  but  have 
an  important  bearing  on  both  pathology  and  practical  physic. 
It  is  not  a  question  of  words,  but  of  deeds.  Were  inflammation 
an  abnormal  increase  of  the  vital  powers  of  the  tissues  affected, 
then  we  cannot  do  better  than  employ  the  many  agents  which 
have  a  direct  power  of  weakening  life,  a  power  which  Boerhaave 
and  Van  Swieten  believed  was  the  only  one  the  art  of  medicine 
could  give.*  Were  inflammation  an  increase  of  vital  powers, 
we  should  value  our  bleeding,  our  blistering,  and  our  evacu- 
ants  in  accordance  with  the  degree  in  which  they  reduce  the 
strength.  If,  on  the  other  hand,  the  phenomena  of  inflamma- 
tion indicate  direct  deficiency  of  vitality,  not  only  in  the  general 
system,  but  in  the  part  affected,  then  we  must  make  the  chief 
end  to  be  kept  in  view  in  our  treatment  the  retention  and  in- 
crease of  vitality.  And  when  we  employ  the  means  I  have 
named,  we  must  look  upon  their  debilitating  action  as  an  ugly 
fault  unfortunately  joined  to  some  other  virtue  which  they 
possess,  and  must  try  to  counteract  the  evil  while  we  retain  the 
good. 

Take  for  example  the  remedy  bloodletting.  Experience 
shows  it  to  be  beneficial  in  certain  cases,  so  let  us  use  it  by  all 
means.  But  all  its  benefits  can  be  rationally  traced  to  its  me- 
chanical hydrostatic  action — to  the  taking  away  of  so  much 
fluid  pressure  which  the  weakened  part  is  unable  to  bear.  Let 
us,  then,  so  apply  the  remedy  that  these  mechanical  phenomena 
should  have  most  play,  by  making  it  as  local  and  as  sudden  as 
we  can,  and  by  using  it  with  a  reference  to  what  we  want  it  to 
do.  And  all  its  evils  can  be  also  rationally  traced  to  its  physio- 
logical action — to  its  detraction  of  so  much  material  of  tissue 
from  the  circulation.  Let  us,  then,  when  we  use  it  for  its  me- 
chanical advantage,  counteract  its  physiological  disadvantages 
by  replacing  to  the  best  of  our  ability  these  materials  of  tissue. 
Instead  of  designedly  starving  our  patients  when  we  bleed,  or 
leaving  the  matter  to  chance,  let  us  designedly  feed  them. 

*  "All  that  art  can  do  is  to  weaken  life."— Van  Swieten's  "  Commentary  ou 
Boerhaave,"  vol.  i,  §  106. 


82  THE  FORMATION  OF  MUCUS  AND  PUS. 

We  may  reckon  in  the  same  way  with  other  remedies  less 
directly  destructive  than  bloodletting.  We  should  value  them, 
not  in  proportion  to  their  special  cvacuant  power,  for  which  they 
severally  are  classified  as  purgatives,  expectorants,  sudorifics, 
&c.,  but  in  proportion  to  the  renewed  growth  of  healthy  tissue 
which  accompanies  their  action.  For  example,  epsom  salts  and 
aloes  are  both  purgatives;  but  take  a  case  of  ansemic  intestinal 
costiveness,  and  Ave  know  well  that  the  more  epsom  salts  the 
patient  is  dosed  with  the  worse  she  is,  but  that  aloes  will  restore 
a  healthy  condition  to  the  mucous  membrane  of  the  bowels,  and 
gradually  reinstate  its  powers.  It  is  not  in  proportion  to  their 
purgative  powers  that  purgatives  are  beneficial,  and  we  can 
hardly  therefore  consider  that  it  is  because  of  these  purgative 
powers  that  they  are  beneficial. 

The  action  of  cantharides  upon  the  skin  as  a  curative  agent 
has  been  established  by  the  common  consent  of  many  genera- 
tions. Is  it  the  blisterinoj  and  destruction  and  drain  of  organic 
matter  set  up  by  the  epispastic  which  does  the  good,  or  is  some 
other  part  of  its  action  ?  Now  in  eczema  and  herpes,  and  in 
smallpox  above  all,  we  have  an  enormous  amount  of  blistering 
and  destruction  of  skin  and  drain  of  organic  matter  ;  but  instead 
of  distant  inflammation  being  arrested  by  them,  or  distant  gene- 
ration of  pus  prevented,  we  often  see  it  produced.  In  smallpox, 
the  more  pustules  there  are  on  the  body  the  more  likely  the 
patient  is  to  have  bronchial  catarrh  and  pneumonia.  Burns  bear 
a  still  closer  resemblance  to  the  morbid  process  set  on  foot  by 
cantharides ;  but  the  greater  the  extent  of  burn  the  more  risk 
there  is  of  internal  inflammation.  Then  remark  the  stage  of 
their  action  when  blisters  do  good  :  their  benefits  are  experienced, 
not  when  the  destruction  of  epidermis  is  at  its  height,  not  Avhen 
there  is  most  serum  and  mucus  and  pus  evacuated,  but  as  the 
healing  begins.  Observe,  for  instance,  a  case  of  water  in  the 
chest  under  treatment :  the  level  of  the  pleuritic  fluid  does  not 
decline  most  rapidly  when  the  blister  on  the  surface  is  filled  with 
serum,  but  when  it  is  drying  up  and  healing.  Is  it  not,  then, 
the  growth  of  new  cuticle  which  restores  our  patient  ? 

In  reckoning  the  beneficial  actions  of  blisters  as  evidence  for 


THE  FORMATION  OF  MUCUS  AND  PUS.  83 

tlie  counter-irritant  theory  of  therapeutics,  we  are  apt  to  forget 
the  cantharidin  which  is  absorbed  by  the  skin,  and  the  direct 
action  of  which  absorbed  drug  on  the  mucous  membranes  is  to 
bring  them  to  a  more  healthy  state.  It  appears,  when  taken  in 
a  fluid  form,  for  instance  in  chronic  bronchitis  and  sometimes  in 
gonorrhoea,  to  be  a  direct  stimuhmt  of  the  vitality  of  these  mem- 
branes. Blisters  may  be  beneficial  in  this  way  quite  independ- 
ent of  their  more  obvious  effect. 

Perhaps  the  most  powerful  for  good  of  all  the  agents  added 
to  the  Pharmacopoeia  of  late  years  is  oil.  During  the  internal 
use  of  oil  the  pus-secreting  tissues  dry  up  and  become  healthy, 
and  their  congested  state  is  diminished.  And  the  more  readily 
assimilated  is  the  form  of  oil,  so  much  the  more  marked  is  this 
improvement ;  that  is  to  say,  the  more  we  saturate  the  system 
with  a  basis  of  growth,  with  a  material  capable  of  being  built 
up  into  new  tissue,  the  less  likely  it  is  to  throw  off  the  material 
of  tissue  in  a  half-formed  state.  The  easy  digestibility  of  cod- 
liver  oil  to  my  mind  more  than  accounts  for  its  wonderful  ef- 
fects, and  makes  superfluous  the  chemist's  aims  to  find  iodine  or 
anything  else  as  a  constant  constituent  in  it.  The  good  we  do 
by  administering  it  is  in  direct  proportion  to  the  largeness  of  the 
supply  of  nutriment  thus  presented  to  the  tissues,  and  bears  no 
relation  to  any  pathogenetic  results. 

In  investigating  the  action  of  drugs,  we  are  sometimes  apt  to 
look  too  far,  and  in  our  search  for  the  mysterious  to  pass  over 
the  obvious.  We  are  apt  to  bestow  too  little  thought  on  the 
immediate  action  of  these  agents  on  the  mucous  membranes  with 
which  they  come  in  contact.  Quinine,  for  example,  inasmuch 
as  it  passes  through  the  blood  so  far  as  to  reappear  in  the 
urine,  doubtless  influences  most  tissues  of  the  body  ;  but  still 
nine  patients  out  of  ten  receive  the  greater  part  of  the  benefit 
accruing  from  the  use  of  quinine  by  means  of  the  augmented 
appetite  and  digestion  which  results  from  its  presence  on  the 
mucous  membrane  of  the  stomach,  not  in  the  blood.  It  seems 
probable  that  the  improvement  in  the  vitality  of  pus-secreting 
parts  which  accompanies  a  course  of  quinine  is  due  to  the  greater 


84  THE  FORMATION  OF  MUCUS  AND  PUS. 

quantity  of  nutriment  which  it  causes  the  mucous  tract  of  the 
intestines  to  absorb. 

The  influence  of  heat  upon  mucus  is  a  suggestive  fact.  If  al- 
lowed to  get  cold,  the  globules  cease  to  develop  the  little  life 
they  have  ;  but  if  kept  at  the  temperature  of  the  body,  they  con- 
tinue to  grow  into  pus  in  spite  of  the  unnatural  circumstances 
in  which  they  are  placed  under  the  microscope.  This  seems  to 
explain  how  hot  fomentations  and  poultices  "favor  suppura- 
tion," as  surgeons  say,  in  boils  and  abscesses.  It  explains  also 
why  suppuration  is  usually  more  rapid  in  deeply  seated,  well- 
covered  parts  than  in  exposed  situations.  But  is  it  wise  thus  to 
"  favor  suppuration  ?"  Yes,  tndy  ;  for  while  we  are  aiding  the 
vitality  of  the  pus-forming  material,  we  are  also  aiding  the  vital- 
ity of  the  surrounding  tissue — we  are  enabling  it  to  recover  that 
perfect  state  in  which  it  need  no  longer  waste  its  nutriment  by 
throwing  it  off  in  a  semi-vitalized  stage  ;  while  at  the  same  time 
the  pus  formed  is  the  most  natural,  the  warmest,  the  softest,  and 
the  least  injurious  substance  we  can  apply  to  a  sore  tissue. 

The  recognized  benefit  of  moist  warmth  may,  I  think,  sug- 
gest to  us  something  more.  When  an  animal  submits  to  the 
periodical  latency  of  the  higher  functions  which  takes  place 
during  sleep,  it  instinctively  seeks  the  warmest  berth  it  can 
find ;  it  is  instinctively  careless  about  the  supply  of  oxygen  so 
that  it  can  get  heat.  Beasts  hide  themselves  in  unventilated 
dens  and  burrows ;  man  surrounds  himself  with  blankets  and 
curtains  in  a  close  bedroom,  and  not  all  the  questionable  argu- 
ments of  busy  philanthropists  can  persuade  him  to  open  his 
window  at  night.  I  suppose  that  instinct  is  hereditary  ex- 
perience transmitted  by  generation  from  sire  to  son,  and  con- 
tinuously increased  through  countless  ages.  It  is  not  surprising, 
therefore,  that  its  silent  voice  should  beat  out  of  the  field  the 
voice  of  argument,  however  loquacious.  But  I  doubt  if  we 
physicians  listen  for  it  carefully  enough.  In  that  state  of  de- 
ficient vitality  which  constitutes  disease,  we  are  sadly  apt  to 
leave  to  accident  the  duty  of  cherishing  the  weak  life  by  warmth. 
In  every  hospital  I  enter,  the  Avards  are  a  great  deal  too  cold. 
Because  their  forefathers  tried  to  keep  the  sick  warm  by  unwise 


THE  FORMATION  OF  MUCUS  AND  PUS.  85 

methods,  the  public  in  the  present  day  zealously  oppose  the 
better  means  of  healthy  warmth  which  new  inventions  provide. 
Can  we  be  surprised  at  rheumatic  patients  falling  into  peri- 
carditis, at  fever  patients  having  pneumonia,  when  house-visitors, 
vigorous  and  well-fed,  walk  in  from  the  park,  and  finding  the 
wards  smell  of  mutton-broth  and  poultices,  order  the  Avindows 
open  without  compunction  ?  Such  things  are;  but  they  might 
be  prevented  if  physicians  would  first  convince  themselves,  and 
then  the  public,  that  an  atmosphere  and  a  temperature  which  is 
agreeable  and  wholesome  to  the  healthy  need  not  be  either  agree- 
able or  wholesome  to  the  sick. 

I  have  endeavored  in  these  three  lectures  to  point  out  with 
as  little  dogmatism  as  I  could,  for  dogmatism  before  such  an 
audience  would  be  ridiculously  misplaced,  the  practical  bearings 
of  a  limited  though  an  important  part  of  the  phenomena  of 
life.  The  formation  of  mucus  and  pus  is  not  indeed  even  the 
whole  of  that  pathological  state  which  we  conveniently  call 
inflammation.  But  I  think  no  harm  is  done  by  pressing  to 
results  deductions  from  even  the  most  limited  observations,  so 
long  as  we  remember  that  they  are  limited,  and  so  long  as  we 
do  not  forcibly  bend  other  observations  into  coincidence  with 
them. 


LECTURE   yi. 

T  YPH-FEVER. 

Case  related — Cause  of  fever —  Why  it  affects  some  and  not  all — 
Case  shoivitig  the  progress  of  fever-poison  cheeked  by  an  emetic 
— Action  of  fever-poison  on  living  organistn — Devitalizing 
potver  on  blood — The  first  symptom  of  partial  death,  a  rigor 
— J^ext  symptom,  pain — Loss  of  appetite,  diarrhoea,  hemor- 
rhage, and  increased  heat,  all  are  evidences  that  disease  is 
something  less  than  life — The  object  of  treatment  is  not  the 
7nere  typh-poiso7i,  but  the  interstitial  death  of  the  tissues — 
The  touchstone  of  restorative  medicine  is  its  application — Use 
of  emetics — Tepid  sponging — Cold  affusion — Supply  of  food 
— Hydrochloric  acid —  Alcohol — L ocal  bloodletting — Princi' 
pal  difference  between  patients  lies  in  the  stomach — Two  in- 
stances— De  duction. 

(^Clinical  Lecture,  given   at   St.   Mary's  Hospital,  October  18, 

18G1.) 

You  saw  a  case  of  continued  low-fever  (or  as  I  shall  call  it  for 
shortness  Typh-fever)  admitted  four  days  ago,  which  presents  a 
good  many  points  valuable  for  instruction. 

Charles  P.,  a-ged  15,  a  shop-messenger,  who  has  grown  rapidly 
lately,  and  has  been  worked  perhaps  rather  beyond  his  strength, 
stated  on  admission  that  he  had  felt  ill,  languid,  and  unfit  for 
exertion  during  the  last  six  weeks.  The  past  fortnight  he  had 
come  home  every  evening  without  any  appetite  for  his  supper, 
and  had  sat  cowerinji;  and  shiverin";  over  the  fire.  For  three 
days  he  vomited  all  food  taken,  had  diarrhoea,  and  pain  in  the 
belly.      Cough  also  had  come  on  with  a  stitch  in  the  right  side 


TYPII-FEVER.  87 

y 

during  inspiration,  and  he  had  expectorated  transparent  mucus 
with  sooty  specks  in  it. 

There  Avere  to  be  seen  on  the  surface  of  the  abdomen  and 
chest  upAvard  of  a  dozen  dingy  fever-spots  in  several  stages, 
some  entirely  disappearing  on  pressure,  some  not.  You  found 
no  pain  or  gurgling  on  pressure  of  the  belly,  and  the  diarrhoea 
was  stated  to  have  ceased.  You  saw  the  patient  prostrate  from 
great  muscular  languor  and  inability  to  stand,  and  a  very  weary, 
dull  look  in  his  eyes.  His  tongue  was  thickly  coated  with  yellow 
fur;  his  skin  was  hot  and  dry;  his  pulse  104,  small  and  sharp. 
His  urine  was  high-colored,  and  deposited  a  copious  yellow  sedi- 
ment, soluble  by  heat.  The  quantity  passed  during  the  next 
twenty-four  hours  after  admission  was  fifteen  ounces,  of  the 
specific  gravity  1-020.  Then  you  noticed  that  the  right  cheek 
was  flushed.  The  lower  part  of  the  right  lung  you  heaid  was 
dull  on  percussion,  and  to  the  listening  ear  there  were  moist 
cracklings  coarse  and  fine  in  it,  and  dry  whistling  sounds  scat- 
tered about  the  rest  of  the  lungs. 

The  boy's  mother  stated  that  they  lived  in  a  healthy  attic, 
dry  and  free  from  foul  odors,  and  could  in  nowise  account  for 
the  illness. 

Here  is  a  sporadic  case  of  one  of  the  low  continued  fevers 
common  in  this  metropolis,  and  which  have  received  a  great 
variety  of  names  according  to  variations  impressed  upon  them 
by  the  epidemic  temporary  constitution  of  the  air  or  the  pecu- 
liarities of  the  individual.  The  two  best-marked  and  best- 
known  varieties  are  called  "typhus"  and  "typhoid,"  dis- 
tinguished by  peculiarities  of  eruption,  and  Ave  hardly  ever  get 
a  case  in  London  which  may  not  either  be  classed  as  one  or  the 
other,  or  be  represented  as  a  transition  between  the  two.  In 
registration  at  St.  Mary's  Ave  make  the  distinction,  and  often 
also  in  speaking  pathologically  of  the  cases.  But  in  treating 
them  I  do  not  do  so;  and  therefore  in  lecturing  about  treatment, 
which  is  the  business  of  a  clinical  teacher,  I  have  adopted  a 
name  which  would  include  both,  from  its  likeness  would  be  gen- 
erally understood,  Avould  not  involve  adhesion  to  any  theory  of 
identity  or  difference,  and  have  in  addition  the  merit  of  short- 


88  TYPII-FEVER. 

ness.      When  I  speak  of  continued  low  zymotic  fever  I  shall  call 
it  "typh-fever." 

The  present  case  has  been  a  good  one  for  study,  for  it  has 
presented  all  the  most  important  symptoms  without  the  patient 
being  so  ill  as  to  be  unable  to  tell  his  story,  or  to  make  the 
repetition  of  it  and  the  examination  by  pupils  dangerous  to  him. 
I  will  call  your  attention  to  what  you  may  learn  from  it. 

There  is  every  reason  to  believe  that  one  of  the  chief  exciting 
causes  of  these  fevers  is  a  poison  generated  by  decomposing 
organic  matter  and  received  into  the  body  from  without.  To 
judge  by  its  effects  it  seems  to  be  widely  diifused  through  the 
air,  especially  in  the  neighborhood  of  its  origin  in  the  air  of 
sewers,  putrid  marshes,  and  crowded  human  habitations.  If 
you  are  readers  of  popular  sanitary  literature,  you  are  probably 
crop-full  of  the  accumulated  and  deeies  repetita  evidence  of  this 
fact.  You  are  tempted  to  ask  how  it  is,  if  the  poison  is  spread 
so  broadcast,  that  everybody  does  not  get  poisoned?  You  will 
wonder  why  it  should  get  into  the  body  of  this  boy,  whilst  you, 
really  much  more  exposed  to  it,  escape.  But  remember  there 
are  two  things  necessary  to  poisoning;  not  only  the  poison,  but 
a  person  apt  to  be  poisoned.  And,  in  point  of  fact,  the  latter  is 
the  most  important  element  in  the  transaction.  It  is  only  on  a 
predisposed  body  that  a  morbid  poison  acts.  Most  likely  we  are 
all  constantly  taking  in  minute  doses  of  the  poison  which  is  the 
exciting  cause  of  these  continued  fevers,  and  can  digest,  oxydize 
it,  or  otherwise  render  it  harmless  under  ordinary  circumstances. 
But  should  some  epidemic  influence  or  exceptional  deficiency  of 
vitality  rob  us  of  the  power  of  doing  so,  then  we  suffer  the 
effects  and  have  typhus  or  typhoid  fever,  as  the  case  may  happen 
to  be.  There  was  reason  enough  for  this  boy  being  the  victim, 
while  others  escaped,  siiown  in  his  recent  rapid  growth  and  in 
his  strength  being  overtasked  by  his  work.  The  exhaustion  of 
vitality  allowed  the  poison  to  do  its  work. 

Besides  this  purely  foreign  mode  of  generation  of  the  poison, 
it  would  appear  capable  of  being  produced  within  the  body  itself 
— out  of  its  own  substance — idiopathically.  At  least  such  a 
closely  similar  train   of  phenomena  follow,  where   an  external 


TYPH-FEVER.  89 

origin  would  seem  a  forced  interpretation  of  nature,  that  we  can 
hardly  help  coming  to  the  conclusion  I  have  stated  in  the  last 
sentence.  Thus  a  tjphous  state  follows  severe  and  disorgan- 
izing wounds,  where  all  noxious  foreign  influences  have  been 
cautiously  shut  out;  and  mere  climatic  agencies,  such  as  the 
unwonted  heat  of  the  sun,  overwork,  chills,  damps,  and  espe- 
cially a  combination  of  these  circumstances,  will  bring  on  the 
well-known  "febricula,"  perhaps  of  only  a  few  days'  duration, 
perhaps  protracted  into  or  (as  some  word  it)  "changing  into" 
a  regular  typhus. 

I  speak  of  the  exciting  cause  of  fever  as  of  a  material  ponder- 
able substance  for  the  sake  of  convenience.  But  I  do  not  wish 
to  exclude  the  possibility  of  its  being  an  immaterial  power  or 
force,  like  light,  heat,  electricity,  or  sound,  are  held  to  be.  If 
it  be  so,  it  is  like  them  associated  wuth  ponderable  matter,  and 
becomes  known  to  us  only  by  means  of  such  association.  We 
speak  of  a  thunder-cloud  causing  certain  phenomena,  although 
we  know  it  is  the  electricity  of  the  cloud  which  does  so ;  of  the 
sun  burning  us  when  we  mean  the  heat  of  the  sun ;  of  a  cannon 
deafening  us  when  we  refer  to  the  vibrations  of  the  air  acting 
on  our  ears.  And  so  we  may  speak  of  the  poisoning  power  as  a 
part  of  that  modification  of  matter  to  which  it  is  joined,  in  spite 
of  that  modification  of  matter  possibly  existing  in  a  similar  form 
(chemically  speaking)  without  being  joined  to  it. 

Observe  how  slowly  the  power  acts  in  some  cases.  Our  patient 
is  upward  of  five  weeks  ailing  before  any  of  the  distinctive  features 
of  his  fever  show  themselves,  and  then  they  creep  out  one  by  one. 
The  time  is  not  usually  so  long,  especially  during  epidemics,  but 
you  may  detect  it  in  the  history  of  almost  every  case.  And  you 
ought  to  notice  it,  because  from  some  systematic  works  you  might 
be  led  to  thinking  that  a  continued  fever  was  easily  to  be  meas- 
ured by  days  and  hours  from  the  very  moment  of  invasion.  This 
is  impossible  in  practice,  and  would  be  of  little  use  were  it  pos- 
sible. 

I  rather  incline  to  think  that  the  most  usual  path  by  which 
the  virus  enters  is  the  digestive  canal,  in  cases  Avhere  it  is  begot- 
ten of  decomposing  organic  matters  foreign   to  the  body.     It  is 


90 


TYPII-FEVER 


probably  mixed  with  the  saliva  and  carried  down  to  tbe  stomach, 
where  it  possibly  may  increase  and  multiply  in  the  gastric  mucus. 
During  severe  epidemics  it  has  been  observed  that  those  who 
smoke  or  chew,  especially  if  they  spit  out  the  saliva  instead  of 
swallowing  it,  are  less  liable  to  be  attacked.*  And  at  an  early 
stage,  even  after  the  virus  has  begun  to  act  upon  the  system,  the 
fever  may  be  stayed  by  emptying  the  stomacli,  and  thus  prevent- 
ing the  whole  dose  being  taken  up.  Those  who  have  watched 
my  practice  will  have  witnessed  several  instances  of  the  success 
of  this  treatment;  they  will  have  seen  the  fever  cut  short,  and 
convalescence  entered  upon  immediately,  with  its  charncteristics 
of  painless  weakness  and  emaciation  gradually  passing  away. 

One  case  last  autumn  gives  me  the  opportunity  of  putting  on 
record  that  the  influence  of  the  remedy  is  not  merely  apparent 
or  accidental,  but  that  it  really  removes  an  essential  part  of  the 
disease.  W.  S.,  a  robust  lad,  aged  15,  came  into  the  hospital 
September  5,  1860,  w4th  hot  skin,  rigors,  excessive  muscular 
languor,  pain  in  the  back,  limbs,  and  head  of  four  days'  dura- 
tion, gurgling  in  the  right  iliac  fossa,  and  rose-spots.  For  the 
first  twenty-four  hours  he  had  no  medicine,  and  the  urine  was 
kept  and  analyzed.  The  result  exhibited  the  following  quan- 
tities of  its  various  constituents  daily  excreted: — 

Grammes. 




__^--- — 

-— -^ 

0        m 

^ 

'>.oE 

a  >-• 

!3 

«  S 

o 

o 

Date. 

111 

5 

< 

'i^ 

3  -^ 
5-< 

=>    s 

— 

.S  33 

3 

^ 

<3       Z 

O 

CO 

'"' 

September  6,  1860,   .  .  . 

1000 

1.027 

50.63 

•43 

•25 

3-48 

3^24 

Then  an  emetic  was  administered,  and  coincident  Avith  a  uni- 
versal remission  of  all  the  symptoms,  the  urine  exhibited  the 
following  remarkable  change  in  tbe  amount  passed  during  the 
next  five  periods  of  twenty-four  hours : — 

*  Mr.  Catlin,  of  American  Indian  celebritj',  attributes  the  comparative  free- 
dom of  his  wild  friends  from  malarious  influences  totbeir  being  tauglit  as  infants 
to  sleep  with  their  mouths  shut,  and  to  their  being  prevented  by  etiquette  in 
after  life  from  ever  opening  them,  except  for  eating  or  speaking. 


TYPII-FEYER. 


91 


Grammes. 


Date. 

a       m 

111 

a      a 
a     g 

5  ? 

5 

■d 
'3 

o 

5 

■r   ^ 

o 

3tJ 

3 

O  _; 

September  7, 

Sept.  8  and  9 ;  mean  of 
two  days'  urine  mixed 

September  10, 

September  11, 

530 

770 
1200 
1320 

1-028 

1-016 
1-011 
1-006 

29-37 

14-79 
18-42 
16-71 

a  trace 

0-037 
0-090 
a  trace 

0-79 

2-68 
4-20 
4-02 

1-97 

1-008 

1-34 

0-96 

1-14 

0-72 
0-32 
0-71 

Now,  the  contrast  between  these  specimens  of  urine  is  exactly 
that  which  is  found  between  the  urine  during  typh-fever  and 
the  urine  during  convalescence.  In  the  first  there  is  evidence 
of  destructive  metamorphosis  going  on  with  extreme  rapidity ; 
in  the  latter  the  destruction  is  overtopped  by  renewal.  And 
this  change  into  convalescence  was  most  strikingly  marked  as 
due  to  the  operation  of  the  emetic.  When  we  see  so  often  the 
immediate  consequence  of  one  dose  of  so  simple  a  remedy,  it  is 
difficult  to  avoid  the  conclusion  that  its  benefit  is  purely  me- 
chanical, and  that  it  acts  by  removing  from  the  mucous  mem- 
brane of  the  stomach  a  poison  only  partially  absorbed  and  still 
adherent  to  it.  Another  reason  for  guessing  that  the  gastric 
mucous  membrane  is  an  early  if  not  the  earliest  recipient,  is 
that  it  early  exhibits  such  special  phenomena  as  usually  accom- 
pany the  ingestion  of  an  unwholesome  material.  Spontaneous 
vomiting  is  very  generally  found  in  the  first  stage  of  the  attack 
(as  you  have  observed  in  the  patient  under  consideration),  and 
seems  to  offer  a  presumption  that  the  part  which  is  then  most 
feeling  the  effects  of  the  poison  is  that  organ  which  most  resents 
it — the  gastric  mucous  membrane.  Such  is  the  evidence  by 
which  I  have  been  led  to  believe  that  the  exciting  cause  of  typh- 
fever  enters  usually  by  the  digestive  canal — valeat  quayitum. 

When  the  poison  has  once  gained  admission  and  is  diffused 
by  means  of  the  circulation  through  the  system,  its  effect  is  to 
destroy  the  vitality  of  a  considerable  amount  of  the  organic 
living  matter  with  which  it  comes  in  contact.  The  destruction 
is  interstitial,  not  local — I  mean,  it  does  not  kill  wholly  a  cer- 
tain spot  which  it  touches,  like  sulphuric  acid,  but  it  kills  only 


92  TYPII-FEVER. 

certain  constituents  of  the  tissues.  The  destruction  is  also 
partial,  not  entire — the  organic  matter  is  by  no  means  utterly 
disorganized,  but  only  brought  down  to  a  less  vital,  less  organic 
condition.  It  may  be  traced  easiest  in  the  changes  found  in 
the  medium  by  which  it  is  diffused.  The  blood,  the  common 
thoroughfare  for  distribution  of  good  and  evil  to  the  tissues,  is 
seriously  changed.  If  you  examine  it  under  the  microscope 
you  will  find  that  the  normally  shaped  red  disks  are  diminished 
in  numbers  as  compared  with  what  pathologists  call  "melanosed" 
corpuscles,  that  is  to  say,  dying  or  dead  disks,  shrivelled  and 
small,  of  a  dark  color,  with  black  specks  in  them,  and  with 
gimped  edges.  In  bad  cases  these  are  unable  to  range  them- 
selves in  rolls,  as  healthy  blood  does  when  it  coagulates;  they 
seem  to  have  scarce  any  attraction  for  one  another  and  lie  in 
amorphous  heaps.  They  dissolve  early  in  the  serum  and  form 
with  it  a  red  fluid.  You  may  trace  this  dissolution  in  the  dusky 
stain  which  the  blood  communicates  to  the  skin  in  typh-fever. 

The  poisoning  apparently  goes  on  very  gradually  in  some 
cases,  and  quicker  in  others.  You  heard  from  this  boy  that  he 
was  five  weeks  ailing  before  he  gave  up  work.  There  was  an 
imperfect  renewal  of  the  body,  shown  by  languor  after  exertion 
and  by  loss  of  appetite  or  deficient  demand  for  new  material. 
But  destructive  assimilation  was  not  checked,  there  was  no  im- 
pediment to  the  carrying  off  of  the  effete  tissues  by  excretion. 
It  may  be  that  in  a  great  many  cases  the  disease,  the  partial 
death,  stops  here,  the  destroyed  tissues  and  their  destroyer 
together  are  disorganized,  are  reduced  to  their  elements  and 
pass  away.  The  idea  is  incapable  of  proof,  but  it  would  account 
for  a  vast  number  of  those  mysterious  languors,  unclassified, 
unnamed,  and  often  unpitied,  which  distress  patients  and  puzzle 
doctors. 

It  is  a  characteristic  of  this  sort  of  virus  to  poison  mainly  the 
nervous  system.  The  fevers  it  produces  get  their  name  from 
then.ce — ricpoc  =  a  smoke  or  mist  overclouding  the  instrument  of 
connection  between  body  and  mind.  In  no  other  diseases  of 
equal  curability  is  it  so  much  affected.  When  therefore  the 
poisoning  has  reached  a  certain  pitch,  and  that  not  a  very  high 


TYPII-FEVER.  93 

pitch,  early  in  the  disease,  the  nervous  system  takes  notice 
thereof,  and  expresses  itself  in  its  most  common  mode  of  taking 
notice  of  partial  death,  namely,  by  a  shivering  fit.  Any  severe 
injury  to  the  bod}^,  a  stretching  of  fibrous  tissues,  an  operation, 
the  fear  of  an  operation,  the  absorption  of  destructive  drugs, 
such  as  antimony  for  example,  will  cause  more  or  less  of  a  rigor 
in  proportion  to  the  sensitiveness  of  the  individual.  And  thus 
also  in  zymotic  fevers,  when  the  interstitial  death  of  the  neural 
constituents  of  the  body  arrives  at  a  certain  degree,  there  fol- 
lows a  rigor.  This  rigor  recurs  from  time  to  time  at  uncertain 
intervals,  but  generally  about  once  a  day,  and  most  commonly 
in  the  evening,  as  the  mother  remarked  in  the  case  which  forms 
the  text  of  my  lecture. 

Then  commences  another  symptom  of  partial  death — pain. 
This  boy  described  his  head,  his  limbs,  and  his  back  as  aching 
all  at  once.  That  is  to  say,  wherever  there  was  most  tissue  with 
sensitive  nerves  in  it,  there  was  found  pain,  indicating  the  dis- 
eased state  of  that  tissue.  Now  this  aching  is  a  symptom  of  the 
earlier  rather  than  of  the  more  advanced  stages  of  typh- fever; 
not  because  there  is  in  the  latter  less  death,  but  because  then 
the  nervous  system  becomes  partially  dead  too,  and  does  not 
feel  so  acutely;  while  in  the  former  it  retains  most  of  its  normal 
sensibility. 

Observe  that  our  patient  tells  us  of  nausea  and  loss  of  appe- 
tite, which  diminished  the  food  eaten — of  vomiting,  which  re- 
jected the  greater  part  of  that  diminished  food — and  of  diarrhoea, 
which  carried  off  the  remainder  scarce  digested  at  all.  Yet  in 
spite  of  all,  the  amount  of  solid  matter  passed  from  the  kidneys 
is  fair;  the  specific  gravity  of  the  fifteen  ounces  of  urine  passed 
in  the  twenty-four  hours  is  1-020,  which  is  a  good  deal  for  a 
person  not  in  strong  health.  The  metamorphosis,  therefore,  of 
the  worn-out  tissues  into  urea  and  salts  is  active;  there  is  a  con- 
tinuous destruction  of  them  in  spite  of  the  defective  supply. 
This  goes  on  so  long  as  the  poison  lasts  in  the  body;  but  when 
it  is  got  rid  of,  the  destruction  ceases ;  no  more  of  the  tissue  is 
metamorphosed  than  is  required  to  make  room  for  new  material, 
and  the  specific  gravity  of  the  urine  falls  during  convalescence. 


94  TYPII-FEVER. 

This  may  take  place  very  suddenly,  as  in  the  instance  I  gave 
you  of  a  fever  cut  short  by  an  emetic;  but  in  general  the  altera- 
tion is  more  gradual. 

I  have  mentioned  the  amount  of  urea,  large  in  proportion  to 
the  nutrition,  contained  in  the  urine  of  typh-fever,  which  is 
rendered  evident  by  its  high  specific  gravity.  There  is  also  an 
increase  very  evident  to  the  naked  eye  in  another  constituent 
of  some  importance,  the  colored  organic  material,  -which  gives 
the  secretion  its  ordinary  hue.  You  saw  how  dark  this  boy's 
water  was,  and  how  deeply  it  stained  the  vessel  from  which  I 
poured  it  on  a  piece  of  white  linen.  We  have  great  reason  to 
think  that  there  is  a  close  alliance  between  this  substance  and 
whatever  it  is  which  gives  the  red  tint  to  the  blood-disks,  and 
that  its  excess  depends  on  excessive  destruction  of  those  im- 
portant little  living  particles. 

The  sulphuric  and  phosphoric  acids  combined  with  bases, 
which  form  a  necessary  part  of  urine,  do  not  in  fevers  follow  the 
lead  of  the  urea;  their  amount  is  less  than  in  health.  Whether 
this  is  due  to  the  destructive  metamorphosis  taking  less  eflfect 
on  the  chief  tissues  containing  sulphur  and  phosphorus,  than  it 
does  on  the  blood  ami  muscles,  is  doubtful.  Dr.  Parke  suggests 
that  perhaps  a  third  of  the  normal  sulphates  and  phos[)hates  of 
the  urine  are  derived  directly  from  the  food,  and  not  from  the 
metamorphosis  of  tissue;  and  therefore  that  their  diminution 
in  typh-fever  may  be  owing  to  the  starvation,  while  the  amount 
which  still  remains  represents  a  fair  proportion  of  destruction.* 

The  chlorine,  in  the  shape  of  chloride  of  sodium,  is  also  in 
small  quantity,  but  not  so  deficient  as  to  lead  us  to  suppose  that 
the  metamorphosis  of  the  chlorinated  materials  of  the  body  does 
not  go  on,  or  that  there  is  retention  of  them  in  the  fluids.  The 
great  quantity  of  chloride  of  sodium  taken  as  food,  and  directly 
mixing  with  all  the  fluids,  again  brings  in  difliculty.  And  an- 
other is  throAvn  in  our  way  by  the  frequency  of  intercurrent 
pneumonia,  which  itself  causes  a  retention  of  the  chlorides 
naturally  excreted  from  the  kidneys.  This  youth,  for  example, 
has  a  little  pneumonia,  and  we  could  not,  therefore,  say  if  ab- 

*  Parkes"On  the  Urine,''  B.  ii,  part  iii,  sect.  4. 


TYPH-FEVER.  95 

sence  of  chlorides  in  his  case  were  due  to  that  inflammation  or 
to  typh-fever.  In  other  cases  our  impediments  to  knowledge 
are  diarrhoea  or  colliquative  sweating,  which  carry  off  chloride 
of  sodium. 

The  diarrhoea  so  frequent  a  companion  of  continued  fever  is  a 
further  evidence  of  death  in  the  blood.  Let  the  fluid  fever  stools 
be  set  aside  in  a  tall  glass,  and  you  will  see  them  shortly  sepa- 
rate into  two  parts;  the  higher  one  a  half-transparent  serum,  in 
which  float  epithelial  scales  and  crystals  of  ammonio-magnesian 
phosphate;  the  lower  stratum  a  greenish-black  flocculent  pre- 
cipitate. This  last  has  no  smell  of  bile,  nor  is  bile  to  be  found 
in  it  by  chemical  tests;  but  it  contains  broken-up  blood-disks 
and  a  great  quantity  of  dark,  granular  coloring  matter — it  is 
just  like  blood  altered  by  the  secretions  of  the  bowels.  And  very 
often  when  you  let  the  stools  separate  in  this  way,  and  look  at 
them  by  transmitted  light,  you  Avill  see  a  visible  sanguineous 
tinge  in  them,  and  blood  mixed  with  mucus  is  visibly  passed 
from  the  bowels.  Blood,  too,  is  not  unfrequently  spat  up  with 
the  mucus  from  the  lungs,  and  drips  from  the  nose;  and  in  bad 
cases  the  dried-up  mucous  membrane  of  the  mouth  cracks,  and 
exudes  the  sanguineous  serum  on  the  surface  of  the  tongue,  pro- 
ducing the  "dry,  brown  tongue"  characteristic  of  severe  fever. 
All  these  prominent  symptoms  call  your  attention  to  the  inter- 
stitial death,  the  lessened  life  of  the  body. 

The  increased  heat  in  fever  is  to  the  careless  observer  rather 
adverse  to  the  doctrine  which  I  have  advanced,  that  all  disease 
is  an  evidence  of  diminished  vitality.  And  in  truth  it  requires 
some  thought  to  see  why  it  is  not  a  conclusive  objection.  But 
an  answer  to  the  idea  of  an  augmentation  of  heat  being  neces- 
sarily an  augmentation  of  life  is  afforded  by  the  fact  of  many 
recorded  instances  of  the  increase  of  corporeal  warmth  having 
taken  place  in  corpses  actually  after  full  death;  so  that,  dis- 
carding at  once  the  notion  of  its  being  a  proof  of  vitality,  we 
may  try  and  trace  what  causes,  really  rather  to  be  associated 
with  death,  may  give  rise  to  it  in  the  cases  under  our  eye.  In 
the  first  place,  in  fever  you  have  a  diminution  of  the  evaporation 
which   takes  place  from   a  healthy  skin,  and  which  acts  as  a 


96  TYPII-FEVER. 

powerful  refrigerator,  as  any  physiologist  who  has  perspired 
knows  full  well.  The  dormant  dry  skin  does  not  do  its  cooling 
office.  Then  in  the  second  place,  there  is  a  much  larger  quan- 
tity of  dead  matter  to  be  evacuated,  and  the  destructive  meta- 
morphosis of  this  dead  matter,  the  semi-vital  chemical  destruction, 
raises  the  temperature,  as  all  chemical  solutions  do.  Wherever 
metamorphosis  is  rapid,  the  temperature  is  raised.  But  this 
metamorphosis  alone,  this  passage  of  living  into  inorganic  mat- 
ter, cannot  be  called  an  increase  of  life,  inasmuch  as  it  indicates 
an  advance  of  death.  It  is  necessary,  may  be,  to  the  removal 
from  the  body  of  poisoned  ingredients,  and  is  so  far  an  advan- 
tage, but  still  it  is  an  indication  of  the  quantity  that  is  poisoned. 

Such  are  some  of  the  most  prominent  consequences  of  the 
typh-poison  in  the  human  body. 

You  may  call  to  mind,  very  likely,  warnings  1  have  given  you 
against  the  old  humoral  pathologist's  doctrine  of  a  materies 
morbi,  which  was  looked  upon  as  the  disease,  and  which  he 
thought  he  has  done  his  duty  by  endeavoring  to  eliminate. 
"Surely,"  you  will  say,  "this  which  you  have  been  describing 
is  a  most  typical  materies  morbi;  if  I  evacuate  this,  I  cure  the 
disease."  Not  so  fast — the  bullet  Avhich  enters  the  soldier's 
ribs  is  a  materies  morbi — have  you  cured  the  disease  when  you 
have  extracted  it?  Nay,  more — suppose  the  bullet  passed  right 
through  the  chest  and  went  out  on  the  other  side,  would  you 
consider  the  disease  gone?  No — the  typh-poison  is  not  the  dis- 
ease, any  more  than  a  bullet,  or  sulphuric  acid,  or  opium  is  a 
disease,  though  each  may  be  a  material  cause  of  disease.  The 
partial  death  which  these  agents  cause  is  the  disease, — is  that 
which  requires  to  be  treated^  and  must  be  the  chief  point  for  the 
physician's  consideration. 

Here  let  us  bring  our  doctrines  to  their  touchstone — bedside 
application.  The  physician  should  ask  himself — What  vitality 
is  wanting,  and  where  is  it  wanting?  And  then — How  shall  I 
easiest  supply  it? 

In  the  first  place,  if  he  sees  the  case  early,  almost  the  only 
thing  he  notices  is  the  lowered  vitality  of  the  stomach — how 
badly  it  digests  its  food,  and  how  it  loathes  its  usual  work.     He 


TYPH-FEVER.  97 

reasons  that  the  functions  are  arrested  by  the  presence  of  some 
poison,  and  he  empties  the  stomach  Avith  an  emetic.  In  manj 
cases  brought  under  treatment  early  in  the  disease,  this  treat- 
ment cuts  it  short  at  once,  as  I  tokl  you  in  a  former  part  of  the 
lecture,  and  as  you  have  had  opportunities  of  observing  in  the 
wards. 

Secondly,  supposing  he  is  too  late  for  his  coup  de  main,  he 
remarks  that  the  skin  is  hot  and  dry,  in  a  great  measure  from 
deficient  perspiration  and  evaporation  on  the  surface  of  the  body. 
He  undertakes  to  supply  that  want  by  an  artificial  moisture.  He 
sponges  the  whole  person  over  three  or  four  times  a  day  with 
tepid  water,  to  which  the  nurses  here  generally  add  some  distilled 
vinegar  to  make  it  more  agreeable.  The  relief  given  is  most 
sensible  and  immediate ;  but  of  course  it  soon  passes  away,  in- 
asmuch as  changes  of  temperature  are  in  their  very  nature  tem- 
porary.    The  sponging  must  therefore  be  frequently  repeated. 

Cold  effusion  is  sometimes  spoken  of,  both  by  opponents  and 
advocates,  as  "checking"  or  "arresting"  the  febrile  heat.  This 
is  apt  to  give  you  a  wrong  notion.  If  it  really  arrested  the  me- 
tamorphosis which  is  the  cause  of  that  heat,  it  would  be  obnox- 
ious to  all  that  could  be  said  against  it.  But  in  fact  it  no  more 
"arrests"  or  "checks"  the  heat  than  emptying  the  bladder 
"  arrests"  the  secretion  of  urine.  A  few  moments'  thought  will 
show  you  that  what  it  does  is  to  remove  the  heat  from  the  ex- 
ternal surface  ;  and  if  it  affects  the  cause  of  heat  at  all,  it  would 
rather  encourage  it  by  making  room  for  more. 

If  the  attendants  have  sufficient  leisure  to  attend  to  an  opera- 
tion which  consumes  a  good  deal  of  time,  it  adds  very  much  to 
the  comfort  derived  from  the  sponging  to  anoint  the  body  with 
some  softly  scented  olive  oil.  This  supplies  the  place  of  the  ar- 
rested sebaceous  follicles,  and  softens  the  skin  for  the  absorption 
and  exhalation  of  Avater.  It  is  a  mistake  to  suppose  that  oil  and 
water  are  at  all  inconsistent,  or  incapable  of  mixing  in  the  sub- 
stance of  living  tissues. 

Where  there  is  pneumonia  in  fever,  or  where  the  patient  has 
recently  had  acute  rheumatism,  I  confess  I  am  somewhat  cau- 
tious about  the  employment  of  aqueous  affusion.     It  sometimes 


98  TYPH-FEVER. 

chills  the  chest  and  causes  an  attack  of  pleurisy  on  the  inflamed 
side,  or  pericarditis.  Besides  which,  in  the  case  of  pneumonia,  it 
interferes  with  a  plan  I  have  of  keeping  a  large  poultice  outside 
the  affected  part,  and  which  I  find  so  heneficial  that  I  do  not 
like  to  omit  it.  For  this  reason  sponging  was  not  ordered  for 
the  present  patient. 

Tltirdhj,  the  physician  sees  that  a  large  supply  of  nitrogenous 
material  must  he  wanting.  The  nitrogenous  tissues  are  devital- 
ized, are  drained  away  dead  in  a  disproportionate  excretion  of 
urea  and  other  organic  compounds,  and  nothing  is  taking  their 
place.  Shall  he  act  antagonistically,  and  try  to  stop  the  pas- 
sage of  urea  hy  the  kidneys  ?  I  do  not  know  exactly  how  he 
would  set  about  it :  but  I  do  know  that  if  he  succeeded,  he  would 
do  positive  harm  ;  for  the  very  worst  cases  of  fever  are  those 
in  which  metamorphosis  is  active  (as  shown  by  the  heat),  while 
the  excretion  of  urea  is  arrested  (as  shown  by  the  lightness  of 
the  urine) ;  they  resemble  cases  of  ursemic  poisoning  from  dis- 
eased kidneys.  The  other  principles  of  treatment  which  I  have 
noticed  in  my  introductory  lectures  would  not  perhaps  be  so 
directly  injurious,  but  common  sense  would  still  allot  the  palm 
to  restoration  here.  Let  it  be  your  chief  aim  to  supply  that 
which  you  clearly  see  is  passing  away — nitrogenous  tissue. 

But  how  will  vou  supply  it  ?  Solid  food  would  in  all  proba- 
bility be  vomited,  from  the  unbearable  loathing  it  excites.  If 
not  vomited,  it  would  lie  for  some  time  a  mere  foreign  matter 
outside  the  mucous  membrane  of  the  digestive  canal,  and  then 
pass  away  by  diarrhoea,  with  much  flatus  and  fetor  and  much 
disengagement  of  gas  during  putrefaction.  Your  beef-stake  might 
as  well  have  been  originally  thrown  down  its  final  destination, 
the  water-closet ;  to  which  it  passes  putrid  though  undigested. 
Neither  is  it  wise  to  fill  the  stomach  with  large  quantities  of 
victuals,  for  the  same  result  follows.  No  "meals"  must,  there- 
fore, be  allowed;  and  prudence  sugests  the  giving  in  their  place 
very  small  doses  of  nitrogenous  aliment  very  frequently.  These 
pass  over  the  irritated  stomach  unconsciously,  and  are  taken  up 
gradually  by  the  intestines,  requiring  but  very  little  to  make 
them  fit  for  absorption.     The  suitablest  food  is  that  which  is 


TYPH-FEVER.  99 

naturally  supplied  to  the  weakest  stomach.  The  feeble  diges- 
tive organs  of  babies  can  assimilate  milk,  and  milk  forms  the 
most  appropriate  nourishment  for  the  debilitated  viscera  of  the 
fever  patient.  Bj  giving  two  or  three  ounces  every  hour  you 
may  get  down  a  quart  and  a  half  per  diem.  But  in  ordinary  in- 
stances every  two  hours  is  often  enough,  and  that  period  is 
adopted  for  the  boy  before  us.  If  there  is  sufficient  acid  left  in 
the  stomach  to  coagulate  the  casein  into  clots,  and  cheesy  lumps 
are  rejected  by  vomiting,  as  happens  sometimes  in  milder  cases, 
you  may  guard  against  this  by  adding  liquor  calcis  or  soda-water 
to  the  milk,  or  you  may  supply  its  place  by  beef-tea.  But  it  is 
the  lumping  of  the  cheese  into  solid  masses  that  it  is  desirable 
to  avoid,  not  the  acidification,  which  is  beneficial.  If  the  patient 
takes  thus  a  good  supply  of  milk  and  beef-tea,  not  only  is  the 
imminent  danger  of  death  by  starvation  avoided,  but  the  emaci- 
ation which  follows  during  convalescence  is  much  less  extreme, 
and  the  dano-ers  in  its  wake  less  formidable. 

Eggs  are  highly  nutritious  food ,  if  taken  raw,  and  diluted 
with  milk  or  water,  they  are  quickly  absorbed.  But  should  they 
be  delayed  and  putrefy,  the  products  of  their  decomposition  are 
peculiarly  injurious  :  the  sulphuretted  hydrogen  and  ammonia 
evolved  are  poisons  to  the  intestines.  I  should  recommend  you 
to  avoid  eggs  till  convalescence  has  restored  the  gastric  pow- 
ers. The  same  objection  does  not  lie  against  milk,  the  lactic 
acid  arising  from  whose  decomposition  assists  in  the  solution  of 
the  casein.  Sour  buttermilk  is  by  no  means  to  be  despised  as  a 
food. 

Fourtlily^  the  physician  should  turn  his  attention  to  the  phar- 
macopoeia, and  consider  what  he  can  cull  from  thence  which  will 
be  of  service. 

You  have  been  taught  in  the  systematic  course  on  medical 
pathology,  that  ammonia,  which  is  always  being  formed  and 
given  off  from  the  animal  body,  is  found  much  more  abundant 
in  certain  conditions  than  in  others,  and  that  these  conditions 
are  those  in  which  nutritive  metamorphosis  or  growth  was  defi- 
cient as  compared  with  destructive  metamorphosis,  or  those  in 
which  there  is  retention  in  the  blood  of  the  products  of  that  de- 


100  TYPII-FEVER. 

structive  metamorphosis.  Thus,  more  ammonia  is  found  in  the 
breath  after  toil  tlian  after  rest  ;  more  than  usual  in  those  who 
hurt  their  digestion  bj  smoking  tobacco  ;  a  great  deal  in  urremia, 
"vvhere  the  urea  cannot  escape  by  the  kidneys  ;  but  above  all  in 
typh-fever  is  this  exhalation  of  decay  noticeable,  as  you  will  find 
in  Dr.  Richardson's  valuable  "work  on  the  coagulation  of  the 
blood,*  Avhcre  the  phrase  "super-alkalinity  of  the  blood"  is  ap- 
plied to  this  condition.  Dr.  Richardson  goes  so  far  as  to  attribute 
to  this  super-alkalinity  the  special  tj^phoid  symptoms,  and  to 
suggest  that  the  absorption  of  ammonia  in  excess  may  intensify 
fever  in  those  who  contract  it  from  exposure  to  decaying  organic 
matter  or  human  exhalations.  He  supports  his  hypothesis  on  the 
experiment  of  inducing  the  symptoms,  or  something  resembling 
them,  by  the  injection  of  ammonia  into  the  veins  of  an  animal. 

The  word  "  super  alkalinity"  is  expressive,  and  quite  unob- 
jectionable, so  long  as  it  is  understood  that  the  superabundance 
is  not  absolute,  but  comparative.  For  it  is  not  shown  that  there 
is  more  alkali  in  the  body  than  there  ought  to  be,  but  more  than 
there  is  acid  to  neutralize.  "  Sub-acidity"  would  be  a  synony- 
mous term,  and  Avould  be  more  sujzgestive  of  the  means  we  have 
at  our  disposal  for  remedying  the  defect. 

Very  difficult  indeed  would  it  be  for  the  eliminator  to  get 
this  alkali  out,  but  it  is  easy  for  the  restoratist  to  get  acid  in. 
The  acid  I  have  always  given  is  hydrochloric,  and  you  conse- 
quently see  on  this  lad's  card — "R.  Acidi  hych'ocldorici  diliiti 
'\X\xx,  syriqn  5j,  aquse  .3J,  altcrvd  qudque  liord  sumat." 

Rich  patients  like  a  little  more  sugar,  but  I  have  not  found 
them  approve  of  the  syrup  of  mulberries  and  barley-water,  in 
which  more  elegant  vehicle  the  late  Dr.  Maton  used  to  give  mu- 
riatic acid  in  fever.  They  say  this  is  mawkish,  and  prefer  the 
cheaper  form,  even  on  the  score  of  taste.  But  it  is  still  more 
approved  of  for  its  beneficial  effects.  This  boy  said  to-day  of  his 
own  accord,  he  hoped  I  should  continue  the  draughts,  they  made 
him  "  feel  so  much  stronger,"  meaning  to  express  a  sensation  of 
relief  to  the  wearisome  languor  of  fever.   In  mild  cases  the  tongue 

*  Richiirdsoti  on  the  •'  Cause  of  the  coagulatiou  of  the  blood,"  Appendix  I. 
(Edit.  1858) 


TYPII-FEVER.  101 

begins  to  clean  immediately,  the  thirst  and  diarrhoea  much  abate, 
and  the  repugnance  to  food  is  diminished. 

In  a  clinical  lecture  at  this  hospital  in  January,  j  858,*  I  gave 
the  details  of  the  first  dozen  cases  treated  on  this  plan,  and  as 
you  are  a  different  audience  from  that  which  heard  me  at  that 
time,  perhaps  I  may  be  allowed  to  repeat  the  sentences  in  which 
I  then  tried  to  interpret  the  beneficial  consequences: — "What 
blood,  when  analyzed,  comes  nearest  in  its  altered  proportions 
to  the  blood  in  low  fever?  Is  it  not  that  of  scurvy  and  pur- 
pura ?  There  is  the  same  excess  of  blackened  (melanosed) 
blood-disks,  the  same  deficiency  of  neutral  salts  and  organizable 
(coagulable)  lymph.  Everybody  treats  these  chronic  affections 
"with  acids,  and  why  not  also  an  acute  affection  which  corres- 
ponds with  them  in  one  point  at  any  rate  ?  As  to  the  particu- 
lar acid  employed,  muriatic  certainly  deserves  to  be  tried  before 
others — first,  because  it  is  such  a  large  constituent  of  the  body 
that  it  might  almost  be  called  a  food  instead  of  Jf  medicine  ;  and 
secondly,  because  it  is  such  a  powerful  arrester  of  the  decompo- 
sition of  animal  matters.  Pour  it  into  a  sewer,  and  you  destroy 
the  miasma.  May  it  not  in  the  body  stop  that  miasma  from 
poisoning  the  tissues?" 

The  allusion  in  the  last  sentence  is  to  chlorine  as  a  disinfec- 
tant. But  I  now  doubt  if  there  is  sufiicient  evidence  of  the 
benefit  derived  from  the  hydrochloric  acid  being  due  to  this 
property.  About  sixteen  years  ago,  I  employed  chlorine  water 
as  a  medicine  in  fever  at  the  Chelsea  Dispensary  ;  yet  I  was  not 
encouraged  to  carry  on  the  treatment  by  tracing  any  benefit  to 
it.  Whether  the  chlorine  which  can  be  introduced  in  this  way 
is  not  sufficient  in  amount  (for  it  must  be  very  dilute,  or  else  it 
will  induce  choking),  or  whether  it  is  really  useless,  I  do  not 
know ;  but  the  inconvenience  caused  me  to  leave  off  its  employ- 
ment. 

Dr.  Pereira  in  his  "  Materia  medica"  speaks  slightingly  of  the 
use  of  hydrochloric  acid  in  putrid  fevers,  and  implies  that  it  rests 
solely  on  exploded  theoretical  propositions.      He  should  have 

*  Printed  in  the  "  Lancet,"'  January  30  and  February  C,  1858,  and  partly  re- 
printed in  the  next  lecture  but  one. 


102  TYril-FEVER. 

noticed  that  Boerhaave  and  Van  Swieten  recommend  it,  and  that 
Sydenham  used  sulphuric  acid  in  these  forms  of  disease  as  an 
antiseptic  drug.  And  these  were  men  not  easily  led  into  erro- 
neous practice  by  a  prevalent  theory.  To  their  experience  I  can 
add  my  testimony,  for  I  have  employed  the  plan  above  described 
in  every  case  of  typh-fevgr  since  the  summer  of  1857,  and  have 
had  yearly  more  and  more  reason  to  speak  well  of  it.* 

Dr.  Pereira,  in  afterwards  speaking  of  its  use  in  dyspepsia, 
gives  a  I'eason  for  its  employment  therein,  that  first,  "  it  is  a  con- 
stituent of  the  healthy  gastric  juice  ;  and,  secondly,  when  mixed 
with  mucus,  it  has  a  solvent  or  digestive  power  in  the  case  of 
various  articles  of  diet."  Is  not  this  as  much  a  reason  for  giving 
it  in  acute  cases  as  in  chronic? 

Whether  tlien,  as  Sydenham  seems  to  have  thought,  any 
other  acid  would  do  as  well  as  the  hydrochloric,  I  cannot  say, 
but  it  forms  so  large  a  constituent  of  the  body  combined  with 
alkali  in  the  blood  and  tissues,  and  free  in  the  solvent  juices, 
that  it  appears  peculiarly  suited  to  the  purpose  on  restorative 
principles. 

As  to  the  use  of  alcohol  in  fevers,  I  am  guided  almost  entirely 
by  the  condition  of  the  nervous  system.  If  there  is  very  com- 
plete prostration  and  delirium  of  a  low  muttering  character,  it  is 
required.  A  tremulous  state  of  the  muscles,  marked  especially 
by  a  quivering  of  the  hands  and  fingers,  is  a  good  test  of  the 
necessity  for  it ;  and  so  is  a  sharp,  weak,  unequal  beat  of  the 
heart.  All  these  indicate  that  the  nervous  system  is  feeling 
very  sensitively  the  destructive  metamorphosis  going  on,  and 
has  its  power  lowered  by  its  sensitiveness.  Then  is  the  oppor- 
tunity for  the  powerful  ana3sthetic  alcohol,  w^iich  in  severe 
cases  you  see  me  order  without  scruple,  but  which  I  do  not  rank 
as  part  of  the  necessary  methodus  medendi  of  fever,  and  have  not 
yet  ordered  for  the  lad  we  have  been  prescribing  for.  Above 
all,  I  would  caution  you  against  employing  it  as  a  substitute  for 
the  treatment  which  I  have  been  describing.      Wine  may  be 

*  This  yearly  growing  experience  is  put  into  numbers  in  a  subsequent 
lecture. 


TYPII-FEVEU.  103 

useful  as  an  adjunct,  but  never  must  it  take  the  place  of  tlic  true 
restoratives. 

There  is,  though,  another  of  the  exceptional  methods  of  treat- 
ment, which  has  been  employed  with  utility  in  this  case— the 
local  abstraction  of  blood.  The  boy  had  congestive  pneumonia 
of  the  lower  part  of  one  lung,  and  I  did  not  hesitate  to  cup  him 
beneath  the  scapula  on  that  side.  And  not  unfrequently  when 
there  is  pain  in  the  right  iliac  fossa,  with  diarrhoea  and  tenesmus, 
I  put  leeches  on  the  belly  at  the  seat  of  pain.  You.  watched  the 
dullness  on  percussion  rapidly  pass  away  from  the  lower  lobe  in 
our  patient  here  ;  and  you  will  often  see  an  equ-il  relief  to  the 
abdominal  congestion  by  the  same  agency. 

But  you  Avill  cry  out  that  I  am  sadly  inconsistent.  I  am 
feeding  up  the  patient  with  one  hand  and  taking  his  pabulum 
vitae  with  another.  The  reproach  is  just  in  a  certain  sense,  but 
that  a  very  limited  one ;  and,  in  fact,  may  be  levelled  against 
half  the  operations  of  daily  life.  We  are  constantly  suffering  a 
small  loss  for  the  sake  of  greater  gain.  And  I  think  the  loss 
of  a  little  blood  is  practically  of  no  moment  at  all  compared  with 
the  advantage  of  securing  a  freer  circulation  through  the  lungs 
or  a  diminution  of  congestion  in  the  intestinal  canal.  Do  not 
be  led  away  by  the  superficial  notion  that  blood  is  blood,  and 
blood  is  life.  Tiiat  is  not  true,  for  blood  varies  immensely  in 
its  composition,  some  being  very  valuable,  and  some  worthless. 
To  lose  a  portion  of  the  half-dead  circulating  fluid  of  fever  is 
but  little  loss,  and  that  little  loss  is  amply  repaid  by  the  addi- 
tional nutriment  which  a  small  bloodletting  will  enable  to  be 
absorbed.  The  deficiency  is  soon  made  up  again  under  a  re- 
storative system  of  treatment. 

In  the  sequelae  of  low  fevers,  more  than  in  any  other  diseases, 
the  great  difference  between  one  patient  and  another  as  respects 
their  poAver  of  recoveiy,  lies  in  their  stomach.  There  is  a  girl 
of  four  years  old  now  in  Victoria  Ward,  who  was  admitted  on 
the  2d  of  September  for  rose-spotted  fever,  which  had  come  out 
during  the  concluding  week  of  August.  She  passed  through 
the  fever  pretty  favorably,  but  for  the  last  seven  weeks  has  had 
a  succession  of  most  formidable  abscesses  in  the  back,  the  cervical 


104  TYPII-FEVEK. 

glands,  the  internal  ears,  and  the  parotid  glands;  yet,  in  spite 
of  the  exhausting  effect  of  the  large  discharge  of  pus  from  these 
spots,  she  has  continued  advancing  in  convalescence,  she  has 
gained  flesh  and  muscular  power,  so  that  now  she  can  sit  up. 
For  this  happy  result  she  has  to  thank  a  most  wonderful  appe- 
tite, which  never  seems  satisfied,  even  with  an  amount  of  food 
which  is  large  for  an  adult,  and  which  she  deliirhts  to  wash  down 
with  wine  and  porter.  No  tonics  seem  of  so  much  use  to  her  as 
an  extra  snack  at  physic  time. 

The  most  striking  recovery  from  these  py?emic  abscesses  after 
fever  you  Avitnessed  last  year  in  a  girl  of  sixteen  (E.  A.,  admitted 
September  28,  186U).  She  had  very  putrid  fever,  accompanied 
by  hgemoptysis,  epistaxis,  and  bloody  discharge  per  vaginam. 
She  got  well  of  her  fever  by  the  help  of  hydrochloric  acid  and 
wine.  But  as  she  became  convalescent  in  the  third  week  of 
October,  she  began  to  have  large  boils  in  the  head;  these  were 
followed  by  abscesses  running  on  into  sloughing  sores  on  the 
back.  Durinn;;  the  first  week  in  November  inflammation  and 
swelling  of  the  left  leg  began.  This  quickly  passed  into  puru- 
lent infiltration  of  the  whole  of  the  left  thigh,  an  opening  in 
which  on  November  28  discharged  two  pints  of  pus  in  twenty- 
four  hours,  and  smaller  quantities  daily  for  several  successive 
weeks.  On  December  12,  there  was  a  large  abscess  in  the 
axilla,  which  was  lanced  and  discharged  several  ounces.  Her 
state  of  debility  was  such  that  she  could  not  in  the  least  help  to 
feed  herself.  Yet  all  this  time  her  stomach  was  in  a  state  that 
a  glutton  would  look  up  to  as  a  seventh  heaven.  She  was 
literally  always  hungry.  As  she  swallowed  her  last  hit  of  beef- 
steak she  would  feebly  ask  when  she  was  to  have  some  more, 
and  what  would  be  her  next  meal;  and  the  way  her  eager  eyes 
followed  any  article  of  food  that  passed  her  bed  was  quite  affect- 
ing. "We  allowed  her  wolfish  appetite  its  full  liberty,  and  fed 
the  punv  maid  like  a  i:ii2;antic  Kh^diator.     The  end  of  the  tale 

r         •/  COG 

is,  that  she  recovered  from  an  amount  of  purulent  disease  which 
it  would  have  seemed  impossible  for  the  human  frame  to  bear — 
and  recovered  perfectly,  for  I  saw  her  in  the  April  of  the  next 


TYPII-FEVER.  105 

year,  looking  as  healthy  and  walking  as  briskly  as  if  she  had 
never  been  ill. 

The  moral  of  these  cases  is  to  do  all  you  can  to  increase  the 
appetite,  and  strengthen  the  digestive  powers.  Reckon  the 
value  of  this  drug  and  that  drug,  one  tonic  and  another  tonic, 
solely  by  the  effect  they  have  on  the  desire  for  food.  If  any 
remedy  lessen  this  desire,  insist  upon  leaving  it  off,  whatever 
authorities  may  have  recommended  it ;  and  form  your  judgment, 
not  from  tradition  or  prescription,  but  from  its  effect  in  the 
particular  case  before  you. 


LECTURE   VII. 
TYPH-FEVER. 

THERAPEUTICAL    STATISTICS.* 

{Clinical,  St.  Marys,  October  17,  1863.) 

I  HAVE  often  spoken  with  confidence  of  the  advantage  of  the 
treatment  you  see  me  pursue  in  fever,  and  I  am  going  to-day  to 
lay  before  you  the  reasons  why  this  confidence  has  been  grow- 
ing yearly  stronger  and  stronger. 

Since  the  opening  of  the  hospital  in  the  summer  of  1851,  to 
the  time  of  my  leaving  London  for  the  vacation  last  August, 
there  have  been  registered  as  under  my  care  230  examples  of 
continued  fever.  Of  these,  109  have  been  treated  on  what  may 
be  termed  "general  principles;"  that  is  to  say,  they  took  neu- 
tral salines  three  or  four  times  a  day,  with  small  doses  once  or 
twice  a  day  of  hydrargyrum  cum  creta,  at  first,  and  later  in  the 
disease,  bark,  ammonia,  ether,  and  wine,  when  these  remedies 
seemed  required  by  the  symptoms.  Leeches  and  cupping  were 
employed  to  the  exterior  of  the  inflamed  viscera  as  occasion 
called,  and  food  was  administered  at  the  ordinary  four  daily 
meal-times.  The  other  121  have  been  treated  on  a  uniform  plan 
of  continuous  nutrition ;  animal  food,  in  a  liquid  form,  has  been 
given  every  two  hours,  day  and  night,  while  the  patients  were 
awake,  and  between  every  dose  of  nutriment  a  dose  of  hydro- 
chloric acid.  They  have  been  sponged  two  or  three  times  daily 
with  tepid  water,  when  the  skin  Avas  hot  and  dry;   and,  in  a  few 

*  The  substfince  of  this  lecture  was  brought  before  the  MeJical  and  Chi- 
rurgical  Socieiy  in  April,  1863,  but  a  few  additional  cases  occurring  between 
that  time  and  August  have  altered  the  figures  a  Utile. 


TYPII-FEVER.  107 

instances,  leeches  or  cupping  h.ave  been  used  to  tlie  exterior  of 
inflamed  localities  in  tlie  abdomen  or  cliest. 

These  two  classes  of  patients  offer  a  fair  basis  for  a  statistical 
comparison  of  the  therapeutical  agencies  brought  into  play :  it  is 
fair  for  the  following  reasons: 

1.  In  the  first  place,  each  series  is  very  nearly  continuous;  all 
the  first-named  109  (with  five  purely  accidental  exceptions,*) 
occurred  in  the  six  years  before  September,  1857,  and  all  the 
latter  121  in  the  six  years  since.  No  fallacy  cun,  therefore, 
arise  from  a  selection  for  special  treatment  having  been  made 
intentionally  or  unintentionally. 

2.  They  are  spread  over  a  considerable  number  of  years ; 
thus  both  sets  include  sporadic  cases,  as  well  as  the  produce  of 
epidemics. 

'6.  They  Avere  all  treated  by  the  same  physician  in  the  same 
wards  of  a  general  hospital  (where  the  cases  are  usually  more 
severe  than  in  special  fever  hospitals),  and  they  nearly  all  come 
from  the  same  group  of  districts  of  which  our  hospital  is  the 
center. 

4.  The  diagnoses  have  been  made  and  the  records  kept  by 
registrars  who  have  nothing  to  do  with  the  treatment,  and  are 
independent  of  the  physician  in  attendance. 

The  only  opening  for  error  that  I  can  discern  is  the  bare 
possibility  of  a  change  of  type  in  fevers  having  taken  place  at 
the  very  time  when  I  changed  the  treatment,  and  of  its  having 
lasted  for  six  years — possibilities  which  the  records  of  other  me- 
tropolitan hospitals  during  the  same  period  reduce  to  nothing. 

That  the  severity  of  the  disease  in  the  two  classes  differed  but 
little  may  be  shown  by  the  near  equality  of  the  periods  of  con- 
valescence. The  mean  time  of  stay  in  the  hospital  of  the  sick 
who  recovered  was,  in  the  first  series,  29-2  days ;  in  the  second, 
26-7  days;  being  a  difference  of  but  2|-  days.     The  ages,  also, 

*  Three  of  these  exceptions  were  treated  on  general  principles  by  a  colleague 
taking  my  duty  during  my  absence,  and  unaware  of  the  experiment  I  was  try- 
ing ;  in  one  case  I  made  a  wrong  diagnosis,  having  mistaken  typh-fever  for  acute 
hydrocephalus,  and  treated  it  with  iodide  of  potassium  till  too  late;  of  the  fifth 
I  have  no  record,  the  patient  having  died  within  two  daj's,  and  the  clerk's  notes 
being  imperfect,  except  as  to  the  fact  of  its  being  a  case  of  fever. 


108  TYPII-FEVEll. 

of  the  two  series  differed  but  little,  the  mean  ago  of  each  being 
between  22  and  23  years. 

These  averages  are  cited  merely  to  show  the  general  similarity 

of  the  two  series,  and  not  to  demonstrate  any  pathological  fact. 

Of  the  first  series  (viz.,  those  treated  on  general  principles), 

9  are  entered  as  Typhus,  and  of  these  there  died     4 

44  "  Typhoid     "  "  16 

56  "  Of  doubtful  or  unrecorded  type    3 


Total  109  Total  23 

Of  the  second  series: 

25  are  entered  as  Typhus,  and  of  these  there  died    0 
52         "  Typhoid  "  "  2 

44         "  Of  doubtful  or  unrecorded  type    2 


Total  121  Total  4 

For  purposes  of  comparison  in  a  therapeutical  inquiry,  it  will 
probably  be  considered  right  to  exclude  from  the  first  t;ible  two 
deaths,  and  from  the  second  table  one  death,  which  occurred 
within  two  days  of  admission  ;  for  the  exhaustion  caused  by  the 
journey  to  the  hospital  in  severe  fevers  allows  but  little  scope  for 
judging  of  the  action  of  treatment  during  that  period.  This 
leaves  the  average  mortality  under  general  treatment  21  in  107 
=  19|  per  cent.,  or  nearly  1  in  5  ;*  under  the  second  method 
of  treatment,  by  continuous  nutriment  and  hydrochloric  acid,  3 
in  121  =  2|  per  cent.,  or  only  1  in  40. 

I  cannot,  therefore,  avoid  the  conclusion  that  the  means  em- 
ployed in  the  cases  on  the  second  list  are  very  efficient  in  pre- 
serving life;  and  that  out  of  every  100  persons  attacked  by  con- 
tinued fever,  from  16  to  17  more  may  be  saved  thus  than  by 
treating  them  on  general  principles. 

The  continuous  liquid  nutriment  given  every  two  hours  con- 
sisted of  strong  beef-tea  and  milk,  of  which  together  about  six 
pints  were  administered  in  the  twenty  four  hours.  The  hydro- 
chloric acid  was  given  every  two  hours  in  doses  of  twenty  minims 

*  This  mortality  is  higher  than  is  usual  at  special  fever  hospitals,  being  about 
the  same  as  at  the  other  general  hospitals  in  London. 


TYPII-FEVER.  109 

of  the  Pharmacopoeal  dilute  acid  in  water  or  eau  sucr^e.  Both 
food  and  drugs  were  seen  by  the  nurses  to  be  swallowed,  and 
not  left  to  the  discretion  of  patients,  who,  from  nausea  and 
occasional  delirium,  cannot  be  trusted  to  help  themselves. 

The  most  immediate  result  of  the  hydrochloric  acid  is  the 
more  natural  condition  of  the  digestive  mucous  membrane,  as 
shown  at  its  two  extremities,  by  the  clearing  of  the  tongue  at 
the  one  end  and  the  cessation  of  diarrhoea  at  the  other.  The 
more  natural  condition  of  the  mucous  membrane  enables  the 
greatest  possible  quantity  of  nutriment  to  be  absorbed  to  take 
the  place  of  the  tissues  poisoned  and  interstitially  destroyed  by 
the  virus  which  is  the  cause  of  the  fever.  That  the  acid  is  in 
any  sense  a  specific,  or  that  it  in  any  chemical  way  neutralizes, 
counteracts,  or  evacuates  the  virus  is,  1  think,  unlikely.  For 
the  mean  period  of  convalcf^cence  in  these  cases  was  shortened 
by  only  2|  days ;  and  certainly  it  would  have  been  shortened 
more  than  that  were  the  virus  removed  or  rendered  inert. 
That  the  convalescence  is  not  more  shortened,  cannot  of  course 
be  judged  of  in  individual  cases,  and  I  state  the  fact  from  the 
statistics  of  the  average  stay  of  the  patients  in  hospital,  which  I 
before  quoted. 

Whether  the  treatment  I  advise  would  be  equally  useful  in  all 
climates,  I  cannot  say,  but  in  Shanghai,  a  climate  as  different  as 
possible  from  England,  Dr.  Henderson*  states  that  its  employ- 
ment diminished  the  mortality  of  continued  fever  from  28  per 
cent,  to  7  per  cent.,  a  very  marked  decrease. 

The  action  of  wine  and  of  emetics  in  continued  fevers  is  not 
attempted  to  be  tested  in  this  inquiry.  In  both  classes  of  cases 
they  were  given;  the  wine,  as  usual,  in  accordance  with  the 
patient's  age  and  the  condition  of  the  nervous  system,  and 
emetics  whenever  the  history  we  could  elicit  made  us  conjecture 
that  the  fever  was  in  its  first  week.  My  impression  is  that  a 
vomit,  when  given  within  the  first  four  days,  materially  lessened 

*  "Medical  Times,"  March  21st,  1863.  I  found  also,  during  a  late  visit  to 
Italy  last  spring,  Dr.  Bishop  of  Naples  equally  convinced  by  experience  of  iis 
value  in  the  low  fevers  in  that  climate,  though  their  usual  type  is  very  different 
from  ours  (Note  to  fourth  edition,  October,  1865). 


110  TYPII-FEVER. 

the  severity  of  the  fever  ;  and  in  some  instances,  seemed  to  cut 
it  short.  But  I  do  not  know  how  to  obtain  numerical  evidence 
on  the  subject.  I  have  never  found  an  emetic  do  harm,  unless 
there  were  antimony  in  it,  when  it  sometimes  caused  or  increased 
diarrhoea,  and  failed  of  the  intended  purpose.  For  this  reason 
I  prefer  plain  ipecacuanha. 


LECTURE    VIII 

TYPH-FEVER. 

Cases  with  running  commentary — Instance  of  a  relapse  of  rose- 
spots —  Contagion  from  patients  to  a  nurse — Leeches  and 
mercury — Blulberry-rash — Intermittent  pulse — Rose-spots  or 
mulberry-spots,  which  most  dangerous? — Wine  in  fevers — 
Retarded  emaciation — Subcuticular  eruption — Contagion — 
Artificial  cuticle  in  bed-sores — Sudamina — Loio  condition  in 
convalescence,  its  symptoms.  , 

[It  may  be  remarked  that  the  date  attached  to  the  ensuing  matter  is  earlier  by 
more  than  five  years  than  that  which  precedes  it  here.  The  cases  are  taken  from 
the  hvtter  half  of  a  clinical  lecture  published  in  the  "Lancet"  of  February  6th, 
1858,  where,  after  nine  others  in  which  general  treatment  was  employed,  are  de- 
tailed the  particulars  of  the  first  twelve  instances  of  the  use  of  the  method  de- 
scribed a  few  pages  back.  It  was  not  necessary  again  to  allude  to  these  patients- 
but  some  of  them  illustrating  points  of  pathological  interest,  and  some  of  them, 
besides  the  common  treatment  of  the  disease,  having  required  that  which  was 
specially  suited  to  each  case,  they  are  here  reproduced.] 

{Clinical,  St.  Mary's,  January  2.^,  1858.) 

[Nine  cases  of  general  treatment  omitted.] 

Case  10.— William  W.  (Case  Book  103,  p.  52).  This  was 
the  deputy  coachman  from  the  infected  house  I  spoke  of  in  Case 
8.  He  had  equal  muscular  prostration  but  not  nearly  so  much 
mental  affection  as  the  housemaid.  On  the  skin  there  were 
rosy  spots,  coming  out  slowly  and  in  consecutive  crops.  One 
peculiarity  in  this  case  is,  that  during  convalescence,  when  walk- 
ing about  and  eating  meat,  he  had  a  relapse,  and  the  rosy  spots 
came  out  again,  with  delirium,  prostration,  &c.,  nearly  as  bad  as 


112  TYPII-FEA'ER. 

at  first.     It  is  very  rare  to  have  a  relapse  of  rosy  petechias,  but 
you  see  it  is  not  impossible. 

Case  11.— Mary  Ann  B.  (C.  B.  103,  p.  G4),  a  nurse  in  the 
hospital,  had  mihl  delirious  fever  without  any  eruption.  I  am 
aiVaid  Ave  must  allow  that  she  caught  it  from  the  patients,  for 
certainly  there  is  no  bad  drainage  here  to  generate  it.  There 
occurs  one  case  now  and  then,  to  show  you  that  low  fever  is  con- 
tagious, and  but  one  to  show  you  that  it  is  very  slightly  so. 

Case  12.— Fanny  A.  (C.  B.  103,  p.  66).  This  girl  com 
plained  a  good  deal  of  pain  in  the  right  iliac  fossa  several  times 
recurring,  which  at  last  was  treated  by  leeches  and  mercury  with 
immediate  relief.  You  may  often  hesitate  about  these  remedies, 
for  fear  of  lowering  the  patient's  strength  by  depletion  ;  but  if 
the  pain  is  made  a  subject  of  complaint,  you  may  feel  safe  ;  for 
the  very  fact  of  the  sensitiveness  of  the  body  shows  that  it  is  not 
too  low  to  bear  them.  Those  who  are  so  much  prostrated  as  to 
make  a  few  leeches  dangerous,  are  insensible  to  slight  pain,  and 
do  not  complain  unless  pressed. 

Case  13. — Emma  B,  (C.  B.  103,  p.  82).  I  never  saw  a  skin 
more  thickly  covered  with  a  mulberry-rash  than  in  this  fine  stout 
brunette  ef  eighteen  ;  yet  few  have  recovered  so  quickly.  She 
came  in  on  October  5th,  having  been  ill  eight  days,  with  a  pulse 
of  120  and  great  prostration;  on  the  6th  her  pulse  was  "80, 
and  intermittent;"  on  the  7tli,  "70,  and  intermittent;"  on  the 
8th,  "natural;"  after  which  medicines  w^ere  left  off,  as  she  was 
convalescent.  I  am  inclined  to  think  that  the  natural  tendency 
to  develop  coloring  matter  exliibitcd  in  the  skin  of  dark  persons 
causes  them  also  to  develop  more  freely  than  others  the  colored 
eruptions. 

You  will  read  in  many  old  books  (and  sound  books  too)  state- 
ments to  the  effect  that  dark  livid  spots  in  fever  are  an  evidence 
of  more  danger  than  rosy  spots,  and  that  the  danger  is  greatest 
when  this  dark  rash  is  most  abundant.  You  will  have  ample 
opportunities  during  your  student  life  of  seeing  that  neither  of 
these  rules  is  applicable  to  facts  as  they  come  before  you. 
There  are  most  deaths  among  the  rose-spotted,  and  you  will  see 
many  cases  of  unusually  rapid  recovery  among  those  with  a  very 


TYPH-FEVER.  113 

copious  eruption.  Yet  for  all  that  I  believe  the  ancients  re- 
ported right.  I  believe  that  the  difference  is  made  by  our  more 
rational  mode  of  treating  our  patients — successful  in  both  sorts 
of  cases,  but  most  especially  in  those  "whei'e  the  livid  rash  shows 
the  chief  force  of  the  poison  to  have  fallen  on  the  blood.  With- 
out wine,  the  most  fatal  cases  would  be  among  the  livid-spotted; 
with  wine,  the  most  are  among  the  rosy.* 

Emaciation  did  not  commence  in  this  patient  till  she  was  so 
far  convalescent  as  to  be  up  and  dressed,  and  then  with  great 
rapidity  she  lost  flesh.  From  the  Avay  in  which  she  withstood 
and  passed  through  the  disease  at  its  height,  you  would  not 
hnve  supposed  her  to  have  been  so  severely  ill  as  she  really 
was.  But  the  quick  destruction  of  all  the  tissues,  and  their 
necessary  renewal  before  the  full  functions  of  life  can  be  per- 
formed, show"  how  pi'ofoundly  the  typhous  poison  affects  them. 
Emaciation  may  be  rather  called  part  of  the  cure  than  part  of 
the  disease;  it  is  nature's  mode  of  getting  rid  of  injured  tissue. 
Case  14.— William  W.  (C.  B.  103,  p.  112).  Pink  spots ;  ab- 
dominal pain  relieved  by  leeches ;  quite  en  regie. 

Case  15.— Edward  P.  (C.  B.  108,  p.  114).  This  robust  man 
was  again  one  of  a  set  where  the  fever  was  traceable  to  a  poison- 
ous locality.  You  may  remember  that  he  made  so  much  noise 
by  yelling  "  Dust-ho  !"  that  he  was  obliged  to  be  removed  to  the 
noisy  ward.  He  turned  out  to  be  a  workman  at  a  neighboring 
dust-contractor's,  and  the  foreman  of  the  yard  was  brought  in 
a  few  days  afterward,  in  Dr.  Alderson's  week ;  and  a  third 
dustman  came  from  close  by,  and  will  appear  as  Case  19.  All 
these  were  very  muscular  men  and  very  noisy.  The  first  and 
second  had  rosy  raised  spots,  which  were  peculiarly  distinct  and 
characteristic  in  Dr.  Alderson's  patient ;  but  the  third  had  a  livid 
rash  ;  and  in  the  first,  Avho  is  at  present  under  review,  there  were 
livid  mixed  with  rose  spots. 

*  Let  me  not  be  supposed  to  say  that  the  use  of  wine  in  ferer  is  a  modern 
discovery.  All  good  authorities  of  all  ages  allow  it  in  exceptional  cases  ;  but 
till  the  present  generation  modes  of  diagnosis  have  not  been  accurate  enough 
to  separate  entirely  idiopathic  fever  and  acute  inflammations  ;  and  therefore  an 
adherence  to  Galen's  condemnation  of  wine  was  really  prudent  in  them  as  a 
rule. 


114  TYPH-FEVER. 

Remark  the  nature  of  this  man's  occupation.  Typhous  mias- 
mata are  perhaps  generated  more  rapidly  when  the  substances 
whence  they  arise  are  wet,  because  moisture  aids  decomposition. 
But  when  once  they  are  produced,  there  is  much  greater  danger 
of  their  diffusion  in  poisonous  amount  from  dry  matters.  Work- 
ers in  sewers  sometimes  get  poisoned  by  sulphuretted  hydrogen, 
but  they  do  not  catch  fever ;  nor  do  the  men  who  cart  night- 
soil  into  the  country  for  manure.  But  when  this  is  spread  out 
on  the  fields,  and  exposed  to  the  sun  and  air,  it  often  causes  a 
limited  epidemic.  So  too,  when  drains  are  dried  up  by  the  sum- 
mer heat,  the  disease  is  more  rife  than  in  seasons  when  they  are 
full.  A  dried  marsh,  and  the  banks  of  tidal  rivers  exposed  at 
low  water,  are  made  more  pestiferous.  So  you  see  sanitary  im- 
provements require  judgment  as  well  as  zeal.  I  believe  the  safest 
mode  of  treating  dust  would  be  to  wet  it. 

You  will  observe  that  hearty  people,  when  they  do  get  low 
fever,  generally  have  it  very  badly,  as  was  the  case  here.  I  sup- 
pose their  system  is  able  to  resist  small  doses  of  the  poison,  and 
when  it  absorbs  large  doses  they  are  the  more  completely  pros- 
trated. Be  careful  not  to  give  a  favorable  prognosis  because  your 
patient  is  a  strong  man :  the  muscular  and  the  corpulent  are  of 
all  the  population  those  who  run  most  risk. 

Case  16.— Caroline  H.  (C.  B.  103,  p.  214).  This  woman  had 
great  pain  on  pressing  the  abdomen,  and  fever  stools.  So  she 
ought,  by  rule,  to  have  exhibited  a  rosy  rash  ;  but  instead  of  that, 
there  was  a  dusky  subcuticular  eruption,  which  is  generally  held 
to  be  of  the  mulberry  sort.  Van  Swieten  describes  it  as  "  lying 
very  deep  under  the  skin,  as  if  nature,  overpowered  by  the  vio- 
lence of  the  disease,  could  not  complete  the  critical  translation 
which  she  had  be";un."*  He  considers  it  a  danrjerous  siern,  and 
I  think  he  is  right,  as  a  general  rule ;  for,  though  this  woman 
recovered,  she  was  very  ill. 

Case  17.— Charles  N.  (C.  B.  103,  p.  228).  This  boy,  again, 
had  livid  spots  accompanying  abdominal  complications,  which 
were  relieved  by  leeches. 

Case  1^.— Mary  D.    (C.  B.  103,  p.  228).     A  washerwoman, 

*  "  Commentaries  on  Boeiliaave,"  vol.  vi,  sect.  T'J.'J. 


TYPII-FEVER.  115 

who  became  affected  immediately  after  receiving  the  dirty  linen 
from  a  house  where  there  had  been  fever  patients.  It  seems  to 
me  difficult  to  avoid  a  conclusion,  that  low  fever  may  become 
contagious  when  the  poison  is  concentrated.  It  is  certainly  wise 
to  act  upon  this  opinion. 

Here  again  I  made  you  remark  the  intcrmlttence  of  the  pulse 
from  debility  during  fever;  and  I  also  called  your  attention  to 
the  natural  appearance  of  the  stools  during  the  height  of  the 
disease,  and  to  their  becoming  liquid  and  fetid  as  the  febrile 
symptoms  declined  and  she' began  to  emaciate.  A  diarrhoea  of 
fsuch  a  sort  at  such  a  time  is  a  very  favorable  occurrence  ;  it  is 
a  critical  discharge  of  the  peccant  humors. 

Case  19.— John  G.  (C.  B.  103,  p.  232).  This  was  the  third 
dustman.  His  pulse  was  also  intermittent,  as  in  three  former 
cases,  but  not  till  he  was  getting  better.  At  first  it  was  not 
above  80,  though  he  was  very  noisily  delirious,  and  had  a  brown 
tongue.  You  may  observe  this  abnormal  slowness  of  fever  pulses 
to  be  particularly  prevalent  in  certain  seasons.  They  have  been 
slower  than  is  quite  consistent  with  the  severity  of  other  symp- 
toms this  winter. 

Case  20.— Stephen  F.  (C.  B.  103,  p.  246).  I  hear  from  Mr. 
Sanders,  of  Chigwell,  who  attends  this  boy's  family,  that  they 
had  fever  with  "mulberry-rash"  in  the  house,  and  that  a  bro- 
ther had  died  of  it.  Stephen  was  sent  to  London  to  be  out  of 
the  w^ay,  but  sickened  on  the  day  of  his  arrival,  and  had  rose 
spots  in  several  crops.  It  is  difficult  to  imagine  the  probability 
of  two  brothers  contracting  different  miasmatic  diseases  in  the 
same  house,  at  the  same  time,  and  from  the  same  cause ;  and  the 
rational  conclusion  would  seem  to  be,  that  both  were  of  the  same 
nature.  It  would  only  be  the  most  overwhelming  evidence  which 
could  lead  us  to  think  otherwise. 

Stephen  was  very  nearly  following  his  brotlier  to  the  grave. 
The  more  propitious  hygienic  circumstances  under  which  he  was 
placed,  in  an  airy  hospital,  instead  of  an  ill-drained  cottage, 
weighted  the  scale  in  his  favor.  I  do  not  see  anything  fresh  to 
remark  in  the  pathology  of  this  case,  except  that  the  patient  got 
a  superficial  sore  on  the  back  by  obstinately  saturating  his  sheets 
with   urine   and   faeces,  and   continuously   rubbing   the   sacrum 


116  TYPII-FEVER. 

against  them.  You  must  distinguish  these  superficial  sores  from 
sloughs,  because  the  same  treatment  will  not  prevent  them.  They 
will  be  produced  by  friction  in  spite  of  a  water-pillow  and  all 
possible  cleanliness,  as  in  this  lad's  case.  The  best  way  of 
managing  them  is  to  paint  the  parts  directly  they  get  red  with 
gutta  percha  softened  in  chloroform,  of  the  consistence  of  paint, 
so  as  to  dry  immediately  on  application.  You  thus  obtain  an 
artificial  new  cuticle,  and  can  renew  it  as  many  times  a  day  £^s 
you  like. 

Case  21.— Henry  G.  (C.  B.  103,  p.  2C)2).  Instead  of  colored 
petechise,  the  eruption  in  this  very  low  case  consisted  of  miliary 
vesicles  scattered  like  fine  seeds  all  over  the  chest  and  abdomen. 
They  are  called  in  the  case-book  "sudamina."  The  word  is  de- 
rived from  their  often  accompanying  excessive  perspiration;* 
but  remark  that  the  association  is  not  a  necessary  one ;  this 
man's  skin  Avas  quite  dry  till  he  became  convalescent. 

Case  22.t— John  B.  (C.  B.  103,  p.  106).  I  have  taken  him 
out  of  chronological  order,  because  he  was  not  treated  by  muri- 
atic acid.  In  fact,  the  fever  had  passed  away,  and  he  might 
be  called  convalescent;  yet  you  saw  him  very  ill,  unable  to  raise 
himself  in  bed,  and  with  a  brown  crust  in  the  center  of  his 
tongue.  On  inquiry  I  found  that  this  low  condition,  remaining 
after  the  special  symptoms  of  the  fever  had  passed  away,  arose 
from  inanition.  Beef-tea,  wine,  and  bark,  set  him  up  directly. 
You  will  see  a  good  many  such  cases  in  dispensary  practice; 
they  die,  though  convalescent,  from  sheer  starvation.  It  is  of 
some  importance  to  recognize  this  fact,  and  you  will  find  the 
most  pathognomonic  sign  is  the  coincidence  of  the  brown  tongue 
with  a  perfectly  clear  mind  and  cool  skin.  These  latter  show 
that  the  typh-poison  has  passed  aAvay,  and  that  the  condition  of 
the  mouth  is  tlie  result  of  want  of  nutriment. 

*  Or  perhnps  from  their  likeness  to  beads  of  sweat  scattered  over  the  skin. 
They  are  very  common  in  Italy,  appearing  on  the  skin  of  persons  with  acute 
rheumatism,  and,  in  short,  all  febrile  diseases  so  generally,  that  "miliary  fever" 
is  considered  by  some  to  be  a  peculiar  disease  sui  generis. 

f  The  numbers  refer  to  the  cases  as  they  stood  in  the  lecture  originally  pub- 
lished in  the  "Lancet"  newspaper. 


LECTURE   IX. 
TYPH-FEVER. 

Part  I. — Three  fatal  cases  since  October,  1861 — One  hrouglit 
in  moribund,  one  treated  with  liydroeldoric  acid,  cj-c,  one  not — 
Four  cases  in  hospital  related,  tvith  comments — Danger  of 
giving  solid  food  too  early  in  convalescence — Absence  of  enteric 
symptoms  best  guide  to  administration  of  solids — Dose  of  hy- 
drochloric acid  for  children — Connection  of  tyidhfever  and 
'pneumonia — Smallpox  caught  during  convalescence  from  typh- 
fever. 

Part  II. — Additional  case,  illustrative  of  the  connection  betiveen 
the  two  forms  of  typhfever  eruptions — Precautions  in  case 
of  threatened  pneumonia — Caution  against  moving  patients  in 
fevers. 

Part  III. — Four  additional  cases,  with  comments.  Case  1. — 
Difficulty  of  distinguishing  typhus  and  e7iteric  fever — Relief 
of  eutopic  pain — Dry,  glazed,  cracked  tongue  in  enteric  cases — 
Arrest  of  diarrhoea  by  hydrochloric  acid,  by  Dover's  poivdery 
^c.  Case  2. — Fever  spots  and  flea-bites — Fever  cut  short  by 
an  emetic — Emaciation  during  convalescence  not  prevented  hy 
the  cutting  short  of  the  fever.  Case  3. — Fever  cut  short  hy 
an  etnetic — When  not  arrestive,  this  treatment  is  palliative. 
Case  4. — Fever  contracted  in  the  hospital  aggravated  nearly 
to  a  fatal  extent  by  inflammation  of  previously  diseased  genital 
organs  and  bladder,  and  by  a  slough  on  the  sacrum. —  Treat- 
ment. 

Part  IV. — Case  of  typh-fever  contracted  in  the  hospital  by  a 
patient  admitted  for  acute  rheumatism — Emetic  only  partially 
successful — Administration  of  solid  food  and  ivine. 

[Clinical,  St.  Mary's,  January  10,  1863.) 

Since  October,  1861,  when  I  last  discoursed  to  you  on  con- 
tinued fever,  it  has  been  more  than  usually  prevalent  in  both 


118  TYPII-FEVER. 

its  enteric  and  typhus  forms,  especially  in  the  latter  form  during 
the  present  session.  I  have  persisted  in  the  employment  of  the 
same  treatment  I  then  commended  to  your  notice,  and  with  the 
same  encouragement  to  proceed. 

There  have  been  two  deaths  among  those  so  treated.  One 
was  in  the  case  of  a  little  boy,  age  unknown,  who  was  carried 
into  the  ward,  December  17,  1861,  quite  unconscious,  cold,  pulse- 
less, with  livid  lips  and  colliquative  diarrhoea.  I  scarcely  can 
tell  hoAV  much  of  the  nourishment  given  him  was  swallowed,  and 
he  did  not  survive  the  morroAV  of  his  entering  the  hospital. 

I  should  have  liked  to  know  in  what  state  this  child  Avas  before 
he  was  brought  away  from  home.  It  is  not  at  all  impossible  that 
he  might  then  have  been  in  a  condition  admitting  of  recovery; 
for  children  very  rarely  die  of  typh-fever,  however  severely  they 
may  have  it.  At  all  events,  it  is  certain  that  the  exhaustion  of 
the  journey  hither  was  the  immediate  cause  of  the  fatal  result. 
The  patient  was,  to  all  practical  purposes  of  restoration,  dead 
before  he  came  inside  the  doors. 

If  your  future  pursuits  should  place  under  your  charge  poor 
people  at  their  own  houses,  I  do  hope  that  events  such  as  these 
(and  they  are  sadly  common),  will  make  an  impression  upon 
you.  Pray  do  not  send  bad  cases  of  typh-fever  out  of  their  beds 
to  be  dragged  in  an  exhausted  state  to  a  hospital.  None  of  the 
advantages  to  be  obtained  there  can  compensate  for  the  chances 
of  life  so  thrown  away. 

Another  death  occurred  in  a  girl  of  eighteen.  I  was  away 
for  my  holiday  at  the  time  of  her  decease,  and  no  post-mortem 
examination  of  the  body  was  permitted  by  the  friends;  nor  are 
the  clerk's  notes  very  explicit — they  seldom  are  in  vacation 
time — but  as  far  as  I  can  judge  from  the  history  given  me  by 
the  ward-sister,  she  seems  to  have  yielded  to  a  very  rapidly  con- 
gestive pneumonia.  I  am  very  sorry  to  have  no  further  informa- 
tion about  her,  as  nothing  is  so  instructive  as  the  investigation 
of  the  causes  of  failure  of  treatment  usually  successful. 

Another  case  of  death  from  the  inflamed  and  ulcerated  bowels 
which  so  often  accompany  typh-fever,  occurred  in  November 
last.     But  she  was  unfortunately  not  treated  in  my  usual  way, 


TYPH-FEVER.  119 

for  a  reason  which  I  will  take  the  opportunity  of  telling  you  as 
a  warning,  as  I  trust  the  same  reason  is  likely  to  be  rare.     The 

patient,  Elizabeth  T ,  was  a  girl  of  eleven  years  old,  who 

was  brought  here  October  24,  with  intense  headache,  deafness, 
delirium,  vomiting,  picking  at  the  nose,  and  other  symptoms, 
which  the  mother  attributed  to  a  blow  on  the  back  of  the  head. 
This  led  to  a  wrong  diagnosis,  and  the  child  was,  by  my  orders, 
treated  with  iodide  of  potassium,  and  blisters  on  the  vertex,  as 
for  inflammation  of  the  brain  ijiydroceplialus  acutus).  I  was 
absent  from  London  at  the  time  of  her  death  also,  but  a  post- 
mortem examination  was  made.  The  brain  was  confrested  and 
wet,  as  it  usually  is  in  those  that  succumb  to  acute  fevers,  and 
have  blood  more  fluid  than  natural.  There  was,  however,  nothing 
like  the  appearance  caused  by  acute  hydrocephalus,  nor  any 
trace  of  injury.  On  opening  the  abdomen,  the  cause  of  death 
was  at  once  referred  to  the  ilia,  which  were  extensively  inflamed 
and  ulcerated  in  the  manner  usual  in  typh-fever. 

I  wish  people  would  more  frequently  put  on  record  mistakes 
made  in  diagnosis;  they  are  full  of  interest  and  instruction  for 
themselves  and  others. 

The  rest  of  the  fever  patients  which  have  passed  through  the 
wards  have  done  well,  and  I  have  no  record  of  anything  note- 
worthy in  their  cases  beyond  circumstances  to  which  I  have 
called  your  attention  in  former  lectures  apropos  of  former  in- 
stances. I  do  not  lecture  to  you  about  by-gone  patients,  except 
they  have  presented  phenomena  unlikely  to  occur  again,  pre- 
ferring to  wait  patiently  till  I  can  illustrate  my  words  from  the 
life. 

I  will  confine  my  remarks,  then,  to  the  four  cases  now  remain- 
ing under  your  eyes,  two  in  the  male,  and  two  in  the  female 
wards. 

Elizabeth  T — ,  aged  twenty-two,  was  made  my  patient  De- 
cember 9,  1862,  with  rose-spotted  fever  of  five  days'  duration 
since  the  introductory  rigor,  with  very  thickly  coated  tongue, 
diarrhoea,  and  severe  pain  on  pressure  of  the  abdomen.  Every- 
thing went  on  well,  no  fresh  spots  came  out  after  the  13th.  On 
the  18th  the  appetite  returned,  and  she  was  allowed  fish  diet  at 


120  TYPIIFEYER. 

her  urgent  request,  although  some  tenderness  remained  in  the 
abdomen,  and  on  the  20th  meat  and  beer.  On  the  25th  it  seems 
her  appetite  had  failed  again  and  she  had  a  rigor  and  some 
vomiting.  When  I  saw  her  on  the  26th  she  was  unable  to  stand  ; 
her  whole  aspect  denoted  a  relapse,  and  I  sent  her  to  bed  with 
a  return  to  my  usual  treatment  of  fever,  dietetic  and  medicinal. 
It  was  a  short  attack,  and  no  spots  were  seen  on  the  skin.  So 
that  on  January  the  7th  she  was  convalescent,  and  is  now  eating 
solid  meat. 

The  remark  I  have  to  make  on  this  case  is  to  warn  you  against 
too  early  yielding  to  the  request  of  patients  for  solid  food.  They 
have  a  fallacious  notion  that  it  is  more  nutritious  than  the  con- 
tinuous liquid  diet  which  is  given  them,  and  in  order  to  get  it 
will  pretend  to  feel  more  appetite  than  they  really  do  feel.  They 
will  also  often  conceal  that  tenderness  of  the  abdomen  which  is 
the  sign  of  the  yet  unhealed  congestion  of  the  mucous  membrane 
of  the  ilia.  I  should  tell  you,  too,  that  when  the  patient  takes 
hydrochloric  acid,  you  are  more  frequently  tempted  to  the  error 
in  judgment  against  which  I  am  warning  you  than  when  they 
have  other  medicines.  The  acid  causes  a  more  rapid  renewal  of 
the  lingual,  and  I  suppose,  at  the  same  time,  of  the  intestinal, 
epithelium :  the  dead,  dirty  coat  is  cleared  away,  and  you  have 
a  clean  tongue  earlier  than  would  otherwise  happen.  I  was 
talked  over  by  the  patient  too  easily  in  this  case,  and  ought  to 
have  been  deterred,  by  the  abdominal  tenderness,  from  giving 
her  meat  so  soon.  The  consequence  was,  the  slight  relapse 
which  you  have  witnessed. 

William  W — ,  a  dirty,  dissipated  looking  person  of  thirty-six 
years  old,  was  sent  to  bed  on  the  30th  ult.,  in  a  state  of  weak- 
ness and  constant  delirium,  which  entirely  prevented  his  giving 
any  account  of  himself;  and  now  that  he  is  getting  well,  his 
memory  of  recent  events  seems  very  dim.  He  was  said,  how- 
ever, to  have  been  ill  a  week,  his  body  was  covered  with  livid 
spots,  his  tongue  was  brown  and  dry,  and  his  tremulous  hands 
kept  picking  at  fancied  objects  before  his  eyes  and  on  the  bed- 
clothes.    There  was  no  diarrhoea  or  pain  in  the  abdomen. 

He  was  treated  in  the  usual  way,  and  had  ten  ounces  of  port 
wine  daily,  with  the  usual  result. 


TYPIIFEVER.  121 

It  is  noted  in  the  diary  that  he  had  some  evacuation  of  liquid 
motions  soon  after  admission,  but  that  the  stool  was  "natural" 
in  appearance.  What  is  meant  is  that  it  was  such  as  is  naturally 
caused  by  a  purgative,  and  not  the  dark  fetid  excretion  of  fever, 
and  in  fact  was  traceable  to  an  emetic  draught  which  was  ad- 
ministered on  admission,  and  which  did  not  cause  vomiting  and 
therefore  went  off  by  the  bowels.  Be  careful  to  distinguish  phe- 
nomena arising  in  the  course  of  disease  which  are  caused  by  art 
from  those  which  are  morbid  and  part  of  its  essence. 

This  man  had  no  real  diarrhoea  and  no  pain  on  pressure  of 
the  abdomen,  and  therefore  I  did  not  hesitate  on  January  7th 
to  order  him  meat  diet  on  his  expressing  himself  desirous  of  it, 
although  he  was  not  sufficiently  recovered  of  his  fever  to  be  able 
to  raise  himself  in  bed;  and  I  feel  confident  he  will  continue,  as 
heretofore,  to  do  justice  to  his  treatment. 

Edward  C — ,  a  boy  of  seven  years  old,  was  seized  on  Decem- 
ber 28th  with  rigors,  nausea,  loss  of  appetite,  nocturnal  delirium, 
and  febrile  depression,  so  tbat  he  could  not  lift  up  his  head.  He 
Avas  brought  under  my  care  on  December  31st,  by  which  time 
there  were  numerous  dusky  fever  spots  on  the  belly.  He  was 
put  upon  the  usual  treatment,  and  is  now  convalescent.  I  have 
to  remark  about  the  orders  on  the  medicine  card,  that  he  took 
the  same  quantity  of  hydrochloric  acid  which  is  administered  to 
adults,  namely,  twenty  minims  every  two  hours,  without  any 
inconvenience  following.  I  have  not  generally  given  such  large 
doses  to  children,  but  shall  know  now  that  it  may  be  done  with 
propriety. 

It  is  remarkable  that  a  few  days  before  this  boy  was  attacked 
by  typh-fever,  without  any  local  complication  whatever,  his 
father  fell  ill  and  was  brought  into  the  hospital  on  December 
29th,  with  pneumonia  affecting  between  one-third  and  half  of 
the  left  lung.  The  father  has  had  no  delirium,  nor  more  nerv- 
ous depression  than  is  accounted  for  by  the  condensation  of  the 
lung,  no  eruption  on  the  skin,  nor  diarrhoea,  nor  anything  Avh'.ch 
would  lead  one  to  set  down  his  complaint  as  due  to  the  same 
cause  as  his  son's.  Yet  the  coincidence,  joined  to  the  fact  of 
their  residence  being  an  ill-drained,  ill-ventilated  house,  where 


122  TYPII-FEVER. 

almost  everj  one  lias  been  ill,  is  too  striking  to  be  passcl  over 
in  silence.  Did  the  exposure  to  cold  and  wet  during  his  daily 
labor  predispose  the  hard-worked  father's  lung  to  be  affected 
by  the  same  cause,  the  typh-poison,  as  absorbed  into  the  boy's 
blood  acted  principally  on  the  nervous  system?  Was  his  more 
robust  frame,  and  the  dura  messorum  ilia  able  to  pass  un- 
scathed a  dose  of  the  typh  sufficient  to  poison  the  more  delicate 
tissues  of  the  younger  subject,  while  at  the  same  time  his  lung, 
devitalized  by  wearing  toil  and  exposure,  yielded  to  its  influ- 
ence? Is,  in  short,  the  pneumonia  the  expression  of  a  quantity 
of  poison  enough  to  injure  a  failing  part  but  not  enough  to  aifect 
his  whole  body?  I  do  not  like  to  answer  these  questions  ex 
cathedrd,  but  I  cannot  help  seeing  some  connection  between 
typh-fever  and  inflammation  of  the  lung. 

The  different  way  in  which  the  same  morbid  agent  afiects 
different  individuals  should  guard  you  against  considering  it  as 
the  disease,  against  looking  upon  illness  as  something  to  be 
evacuated  or  neutralized.  The  disease,  that  against  Avhich  you 
have  to  struggle,  is  the  partial  deficiency  of  life  caused  by  this 
morbid  agent,  and  your  struggles  must  take  different  forms  ac- 
cording to  the  different  forms  of  the  deficiency. 

The  fourth  case  of  typh-fever  still  in  the  hospital  is  that  of 
Sarah  H — .  She  is  a  married  woman,  aged  twenty-eight,  of 
slim  figure,  and  not  muscularly  strong.  She  was  admitted  De- 
cember 5,  having  rose-spotted  fever  of  three  days'  duration  since 
the  rigor,  and  accompanied  by  delirium.  As  is  usually  the  case 
with  delicately  framed  susceptible  females,  the  nervous  system 
was  especially  affected :  we  were  forced,  in  addition  to  the  usual 
fever  treatment,  to  give  her  a  great  deal  of  port  wine ;  the  belly 
became  tympanitic,  and  I  was  at  one  time  seriously  alarmed 
about  her.  However,  on  December  18  she  was  in  her  right 
mind  and  convalescent,  though  unable  to  raise  herself  from  the 
lying  posture  for  her  natural  evacuations. 

I  mention  the  fact  of  her  being  quite  confined  to  bed  for  a 
special  reason.  On  the  last-named  date  there  was  in  the  ward 
for  a  few  hours,  a  patient  who  was  discovered  to  have  variola, 
and  was  sent  off  to  the  Smallpox  Hospital.     Now,  Sarah  H — 


TYPII-FEVER.  123 

was  the  only  unvaccinated  person  in  the  ward,  and  the  con- 
sequence was  that  she  received  the  infection,  and  has  since  gone 
through  a  severe  attack  of  the  confluent  form  of  smallpox.  In 
spite,  however,  of  having  thus  imbibed  a  new  poison,  she  con- 
tinued to  increase  in  health  and  strength  till  the  30th.  On  the 
morning  of  the  31st  she  had  a  decided  rigor,  she  became  fever- 
ish, lost  her  appetite,  and  had  nausea.  The  pulse  rose  to  110. 
Thinking  she  was  about  to  have  a  relapse,  like  the  first  patient 
to  whom  I  drew  your  attention,  I  put  her  back  on  the  usual 
fever  treatment,  which  she  has  continued  to  have  ever  since. 

One  piece  of  information  you  may  gain  from  the  accident  of 
this  unfortunate  patient  having  the  two  diseases  so  close  upon 
one  another,  is  the  fact  that  typh- fever  does  not  prevent  a  per- 
son receiving  the  infection  of  smallpox.  A  second  is,  that  the 
presence,  in  a  latent  state,  of  the  morbid  poison  which  gives  rise 
to  the  latter  disease,  does  not  retard  the  progress  of  convalescence 
from  the  former;  and  is  in  reality  dormant  as  well  as  latent.  A 
third  is,  that  on  the  whole,  the  sufferings  from  smallpox  are  more 
severe  than  those  from  typh-fever.  Our  patient  declared,  at 
first,  that  the  fever  was  the  worst  of  the  two,  but  by  the  time 
the  pustules  had  completely  maturated,  and  she  was  sore  all  over, 
she  frankly  confessed  to  me  her  error. 

{Clinical,  St.  Marys,  February  13,  1863.) 

On  Ellen  D — ,  a  servant  girl,  aged  sixteen,  who  came  under 
your  observation  three  days  ago  with  typh-fever  of  a  week's 
duration,  you  have  seen  an  instance  of  the  two  most  common 
forms  of  eruption  in  this  disease.  The  bosom  and  abdomen 
were  thickly  covered  with  dark  livid  spots,  many  of  them  as 
deep  purple  as  those  of  purpura  hcemorrhagica.  She  was  in  a 
very  low  state,  the  blood  being  very  venous.  Yesterday,  in  ad- 
dition to  the  purple  spots,  I  observed  on  the  abdomen  several 
spots  slightly  raised  above  the  surface  of  the  skin,  and  of  a  much 
more  pinkish  hue.  Her  hair,  and  probably,  therefore,  her  skin 
are  naturally  dark,  so  the  maculae  are  not  so  pink  as  they  would 
be  in  a  blonde  complexion;  but  still,  no  one  would  hesitate  to 


124  TYPII-FEVER. 

call  tliem  "typlioid"  spots.  This  shoAvs  jou  the  great  difficulty 
that  lies  in  the  question  of  whether  there  are  two  distinct  animal 
poisons  causing  "typhoid"  and  "typhus"  fever.  Doubtless,  it 
is  not  impossible  that  both  may  exist  in  the  body  at  the  same 
time,  and  give  rise  to  two  distinct  fevers  at  the  same  time ;  just 
as  a  person  might  be  poisoned  by  a  mixture  of  strychnine  and 
antimony,  and  exhibit  the  effects  of  both  drugs  together.  But 
in  the  case  of  morbid  poisons  which  increase  in  the  body,  such 
a  joint  progress  shows  at  least  a  very  close  relation  between  the 
two.  There  are  also  other  instances  where  the  eruption  seems 
to  exhibit  a  transitional  character,  or  wliere  there  is  not  a 
sufficiently  distinctive  eruption.  In  our  register  these  cases 
are  not  distinguished,  but  are  entered  simply  as  "fever."  If 
then  there  are  two  poisons  which  cause  typh-fever,  a  point  I 
consider  not  proved,  they  must  be  much  nearer  allied  to  one 
another  than  those  which  originate  the  usual  eruptive  fevers, 
such  as  scarlatina,  smallpox,  &c. 

You  may  have  observed  that  I  am  loose  in  my  nomenclature 
of  this  class  of  diseases,  speaking  sometimes  of  "common  con- 
tinued fever,"  sometimes  of  "continued  fever,"  sometimes  of 
"low  fever,"  sometimes  of  "typh-fever,"  sometimes  of  "fever" 
simply,  when  I  mean  the  same  thing.  This  is  not  from  careless- 
ness, but  to  show  you  my  opinion  that  for  therapeutics,  to  which 
the  greater  part  of  my  clinical  lectures  refer,  the  name  is  unim- 
portant; and  also  because  the  terms  "typhoid"  and  "typhus," 
having  acquired  a  special  limited  meaning,  and  when  used  by 
me,  being  used  in  that  special  limited  meaning,  are  unsuited  to 
my  general  purpose.  Their  employment  would  seem  to  prejudge 
a  question  upon  which  I  am  not  engaged  in  this  chair. 

I  should  advise  you  also  not  dogmatically  to  prejudge  the 
question.  Use,  if  you  like,  the  popular  nomenclature,  but  do 
not  be  skeptical  of  the  possibility  of  the  eruptions  being  pheno- 
mena of  one  morbid  poison,  varied  by  varying  circumstances, 
any  more  than  you  are  skeptical  about  their  being  indications  of 
two  poisons. 

There  is  no  necessity  for  being  in  a  hurry  to  decide,  for  it  is 
not  a  matter  of  any  importance   to  yourself  or  your  patient. 


TYPII-FEYER.  125 

Both  forms  of  disease  are  infectious  to  a  certain  extent,  as 
occasional  instances  in  the  wards  show  you.  Typhus  is  said 
to  be  most  so,  perhaps  from  its  following  a  larger  dose  of  the 
poison  ;  but  neither  are  very  infectious,  and  do  not  require  the 
extraordinary  precautions  proper  for  smallpox,  measles,  or  scar- 
latina. And  both  call  for  the  same  treatment,  and  are  accom- 
panied, though  in  varying  proportions,  by  the  same  local  in- 
flammations. 

AVhile  on  the  subject  of  typh  eruptions,  I  may  take  the  oppor- 
tunity of  warning  you  uot  to  limit  your  observations  solely  to 
the  surface  of  the  chest  or  abdomen,  as  is  very  commonly  done. 
The  flanks  and  buttocks  are  often  the  seat  of  them,  and  I  have 
sometimes  found  spots  very  marked  and  indubitable  in  these 
situations,  when  their  presence  elsewhere  was  doubtful.  In 
females  especially  it  is  convenient  to  find  them  liere,  as  it 
obviates  the  necessity  for  baring  the  front  of  the  person,  a  pro- 
ceeding naturally  repugnant  to  a  delicate  mind.  Of  course  if 
they  are  not  there  you  must  examine  the  more  usual  habitat. 

In  this  girl  there  was  great  general  congestion  of  the  lungs; 
the  respirations  were  much  hurried,  amounting  to  thirty  in  the 
minute;  there  were  sibilant  rtxles  all  over  the  chest,  most  intense 
at  the  back  part ;  but  there  was  no  localized  dullnes  on  percus- 
sion. In  consequence,  I  believe,  of  this  congestion,  the  pulse 
was  quicker  than  usual,  beating  140  in  the  minute;  for  you 
will  rarely  find  it  above  120  when  the  pulmonary  tissue  is  in  a 
healthy  state. 

When  there  is  such  an  amount  of  congestion  as  to  produce 
marked  dyspnoea,  it  is  better  to  omit  the  usual  sponging  of  the 
surface  of  the  body,  or  you  run  the  risk  of  pneumonia.  This 
had  been  done  in  the  present  instance,  and  the  chest  has  been 
enveloped  in  a  "jacket  poultice."  She  now  breathes  easier,  has 
less  cough,  and  the  pulse  has  sunk  to  110,  getting  stronger  at 
the  same  time.  The  even  temperature  of  a  poultice  is  by  far 
the  most  powerful  means  of  restoring  the  deficient  vitality  of 
the  lungs,  where  that  deficient  vitality  is  general;  I  mean  when 
the  pneumonia  is  not  circumscribed. 

You  may  observe   that  very  many  patients  say  on   the  first 
9 


126  TYPII-FEVER. 

visit,  that  they  are  "worse  than  before  they  left  home  to  come 
into  the  hospital.  Sometimes  even  deaths  occur  within  the  first 
thirty-six  hours,  of  which  I  related  you  an  instance  in  a  former 
lecture,*  the  patients  being,  in  fact,  death-struck  from  the 
moment  of  admission.  This  arises  from  the  exhaustion  induced 
by  the  journey  hither,  of  which  you  may  always  see  traces, 
however  short  it  may  be.  Removal  even  from  the  next  street 
does  harm,  and  the  harm  increases  in  a  mathematical  ratio  to 
the  time  and  distance  required.  Bringing  patients  in  from  a 
great  way  is  most  murderous;  no  excellence  of  nursing  or 
superior  comforts  can  atone  for  the  risk  run.  As  far  as  we 
possibly  can,  we  limit  our  reception  of  typh-fever  to  the  neigh- 
boring parishes,  and  prevent  persons  from  a  distance  being 
admitted,  if  we  hear  beforehand  of  their  coming.  And  once 
within  the  walls,  they  are  spared  every  unnecessary  movement; 
they  are  sent  upstairs  to  bed  in  the  lift,  not  allowed  to  raise 
their  heads  from  the  pillow  to  drink,  and  are  supplied  with  a 
bed-pan  for  the  other  calls  of  nature. 

In  typh  fever  everything  depends  on  sparing  most  avariciously 
the  little  vital  force  that  remains.  You  will  have  reason  to  re- 
gret every  muscular  exertion  that  you  allow  patients  to  make. 
I  was  called  lately  to  Hertford  to  see  what  seemed  to  have  been, 
and  to  be,  a  very  moderate  case  of  fever  with  intestinal  affection. 
None  of  the  distinctive  bad  symptoms  peculiar  to  the  disease  had 
showed  themselves.  But  unfortunately  the  patient  had  been  at 
Brighton  Avhen  taken  ill ;  she  pined  for  home,  was  allowed  to 
move  thither,  and  never  rose  from  the  prostration  caused  by 
the  journey.  I  have  heard  of  cases  where  the  permission  to 
sit  up  in  a  chair,  instead  of  lying  in  bed,  has  resulted  in  fatal 
prostration. 

You  will  find  of  course  more  obstinacy  on  this  point  among 
the  upper  classes  than  the  lower,  and  you  will  sometimes  have 
great  difficulty  in  overcoming  it.  But  it  is  your  duty  to  try 
and  do  so;  and  should  patients  persist  in  disobeying  orders  to 
keep  quiet,  I  advise  you  rather  to  cease  your  attendance  than 
to  give  way.  You  niust  not  allow  people  to  sacrifice  your  good 
fame  as  well  as  their  own  lives. 

*  January  lOlh.     See  page  117. 


TYPII-FEVER.  127 

[Clinical,  St.  Marys,  March  6,  1863.) 

Eliza  C — ,  a  stout  muscular  girl  of  eighteen,  was  received 
February  27,  with  the  usual  symptoms  of  continued  fever.  The 
eruption  was  at  first  of  a  doubtful  character;  nobody  could  have 
decided  accurately  whether  the  spots  were  a  pale  example  of 
those  usually  called  typhus,  or  whether  they  were  fading  typhoid 
spots.  This  difficulty  is  one  of  the  many  which  beset  the  investi- 
gation of  the  question  of  their  identity  or  non-identity.  Inas- 
much, however,  as  from  the  same  house  her  sister  was  at  the 
time  under  my  care,  and  an  aunt  had  just  died  with  indubitable 
typhus,  I  thought  it  very  likely  her  eruption  would  exhibit  the 
same  variety  of  appearance.  But  no — it  proved  not  so,  for  since 
then  many  rosy  spots,  slightly  elevated  above  the  surface  of  the 
skin,  have  come  out  in  successive  crops.  I  mention  this,  be- 
cause these  rosy  spots  are  a  warning  to  the  physician  that  he 
may  expect  inflammation  of  the  intestines.  And  the  warning 
has  been  justified  in  this  case;  for  the  patient's  principal  com- 
plaint during  the  last  few  days  has  been  pain  in  the  abdomen, 
aggravated  by  pressure  of  the  right  iliac  fossa,  and  much  light- 
ened by  a  linseed  meal  poultice.  There  is  nothing  does  patients 
with  enteric  symptoms  so  much  harm  as  moving  about  and  the 
impression  of  dry  cold,  and  nothing  does  them  so  much  good  as 
lying  quite  still  on  the  back  and  applying  moist  warmth.  A 
poultice  accomplishes  both  objects,  it  keeps  the  patient  im- 
movable, and  acts  as  a  sort  of  perpetual  Avarm  bath  to  the  ab- 
domen. It  entails  of  course  abstinence  from  the  sponging 
treatment. 

Another  warning  of  enteric  inflammation  was  seen  in  her  dry 
tongue,  without  much  coating  of  epithelium,  and  with  transverse 
cracks  from  side  to  side.  It  is  seldom  that  you  see  a  tongue 
like  this  Avithout  the  intestines  being  inflamed. 

This  girl  has  had  scarcely  any  diarrhoea.  The  fact  is,  that 
the  hydrochloric  acid  treatment  always  prevents  the  diarrhoea 
of  fever  from  attaining  any  prominence  as  a  symptom.  There 
is  usually  just  about  enough  to  show  what  it  would  be  if  not 
stayed.     Should  the  hydrochloric  acid  alone  be  not  sufficient, 


128  TYPII-FEYEK. 

the  diarrhoea  is  best  treated  by  Dover's  powder,  both  the  opium 
and  the  ipecacuanha  in  that  preparation  being  good  for  dysen- 
teric inflammation.  Kino  powder  is  also  apphcable  to  such 
cases;  but  chalk  is  of  course  out  of  the  question  while  you  are 
administering  hydrochloric  acid. 

Thomas  W — ,  a  robust  boy  of  sixteen,  was  brought  here 
February  28,  with  symptoms  of  low  continued  fever  of  three 
days'  duration.  There  was  xerj  great  depression  when  the 
resident  medical  ofiScer,  Dr.  Rhodes,  saw  him  then,  and  he  fully 
expected  it  was  going  to  be  a  very  bad  case.  He  ordered  an 
emetic  immediately,  and  the  consequence  was  the  vomiting  of  a 
quantity  of  blackish  matter  like  semi-digested  blood.  "When  I 
saw  the  lad  the  next  day,  he  was  so  brisk-looking  in  the  face, 
and  exhibited  so  little  febrile  depression,  that  at  first  sight  I  was 
disposed  to  question  Dr.  Rhodes'  diagnosis.  But  then  I  was 
shown  the  abdomen  and  chest  covered  with  small  purple  spots. 
Even  then  I  was  not  convinced,  and  put  the  spots  to  the  test  of 
examination  by  the  microseope.  I  thought  they  might  be  flea- 
bites. 

Now,  fleas  cannot  leave  their  marks  without  a  puncture,  and 
in  all  flea-bites  you  may,  with  a  lens  of  very  moderate  power,  if 
not  with  the  naked  eye,  delect  this  puncture  as  a  very  minute 
dark-crimson  point.  The  spots  stood  this  test,  there  was  no 
puncture,  and  they  were  certainly  purpuric  typhus  spots,  which 
have  since  faded  away.  But  how  is  it  that  he  had  and,  indeed 
has  had  since,  so  little  febrile  depression?  The  fact  is,  this  is 
one  of  those  fortunate  cases  of  a  fever  cut  short  by  an  emetic. 
He  is  now  emaciating,  and  emaciating  extensively,  and  conva- 
lescent. 

In  the  last  sentence  I  laid  some  stress  on  the  word  "emaciat- 
ing." The  emaciation  is  a  phenomenon  of  great  interest;  it 
shows  how  large  an  amount  of  tissue  is  interstitially  poisoned  in 
typh-fever ;  how  large  an  amount  requires  to  be  carried  off  by 
destructive  metamorphosis  during  the  renewal  of  life.  In  such 
cases  as  this,  when  the  fever  is  cut  short,  it  by  no  means  follows 
that  the  emaciation  should  be  cut  short,  and  in  point  of  fact  it 


TYPII-FEVER.  129 

is  not  so.  The  removal  of  the  destroyed  tissue  is  a  necessary 
part  of  the  case. 

Strokes  of  good  fortune  are  sometimes  equally  gregarious 
with  the  proverbially  "seldom  single"  misfortunes.  Next  bed 
to  the  boy  lies  a  young  man  whose  fever  has  been  in  the  same 
way  cut  short  by  an  emetic.  Thomas  B — ,  aged  nineteen,  ex- 
hibited on  the  3d  of  March  the  usual  symptoms  of  continued 
fever  of  three  days'  duration.  There  have  been  all  along  but 
few  spots,  and  those  of  obscure  indeterminate  character  on  the 
abdomen.  But  he  had  the  aspect  of  being  very  ill,  and  his 
tongue  was  thickly  coated  with  yellow  fur,  and  showed  a  ten- 
dency to  get  dry.  He  was  treated  in  the  same  way  as  the  last 
patient,  with  an  emetic  and  hydrochloric  acid,  and  has  entered 
fortluvith  upon  convalescence.  It  is  now  nearly  two  years  since 
I  have  had  a  case  of  fever  so  decidedly  cut  short  by  an  emetic ; 
so  do  not  expect  it  often.  But  nearly  all  have. the  violence  of 
the  disease  alleviated  by  that  remedy;  so  that  it  is  never  out  of 
place  during  the  first  week  of  the  fever. 

Emily  H — ,  aged  twenty-six,  married,  was  entered  to  the 
ward  assigned  to  uterine  diseases,  for  irritability  of  the  bladder 
arising  from  antiversion  of  the  womb,  in  middle  of  last  month. 
On  the  2d  instant  she  was  taken  with  feverishness,  loss  of  appe- 
tite, and  pains  in  the  head  and  back.  She  had  a  rigor  that 
night;  she  was  transferred  to  me  yesterday,  and  then  there  were 
obscure  livid  spots  on  the  abdomen,  and  pain  on  pressure.  She 
has  been  put  on  the  usual  treatment,  and  it  appears  likely  to 
prove  a  mild  case  of  typhus  fever.  I  only  mention  it  here  as 
having  been  apparently  contracted  in  the  hospital,  which  I  am 
glad  to  say  is  not  a  common  occurrence. 


{Clinical,  St.  Marys,  March  20,  1863.) 

Emily  H — ,  about  Avhom  I  said  a  few  words  on  the  day  after 
her  coming  under  my  care,  has  given  us  more  anxiety  than  I 
looked  for.  Iler  antiversion  of  the  uterus  had  been  treated  by 
a  pessary,  and  her  delirious,  semi-conscious  state,  caused  by  the 


130  TYPII-FEVER. 

fever,  prevented  her  making  this  known  to  the  nurse.  The  in- 
strument was  removed  immediately  that  it  was  discovered,  and 
was  followed  by  an  excessively  fetid  discharge  from  the  vagina, 
which  lasted  some  days.  A  vaginitis  had,  in  fact,  been  produced 
by  the  pressure,  easily  enough  borne  by  a  healthy  vagina,  but 
acting  destructively  on  that  part  when  its  vitality  Avas  lowered 
by  general  disease.  I  was  fearful  that  the  patient  was  going  to 
have  internal  sloughing,  but  she  has  escaped  by  good  fortune 
and  the  use  of  an  injection  of  decoction  of  cincliona  and  chlori- 
nated soda.  She  has  escaped  so  far  as  her  generative  organs 
are  concerned,  but  not  altogether;  the  vaginitis  and  fever  united 
entirely  paralyzed  the  sphincters  of  the  bladder  and  of  the  rec- 
tum, and  it  was  impossible  to  prevent  the  pillow  on  which  her 
sacrum  lay  from  being  soaked  with  the  excretions.  Her  constant 
delirium  also  made  her  very  unmanageable  at  first.  We  could 
not  prevent  the  pressure  on  the  sacrum,  and  the  consequence  is 
that  a  rather  deep  slough  has  formed  there. 

This  woman  afforded  an  example  of  how  the  mental  qualities, 
as  well  as  the  corporeal,  suffer  degradation  in  illness.  During 
her  raving  she  was  constantly  attempting  to  practice  masturba- 
tion, and  was  uncurbed  by  shame,  so  that  the  nurse  was  obliged 
to  be  constantly  on  the  watch  to  withhold  her.  I  have  no  reason 
to  suppose  her  generally  a  vicious  person,  and  in  recovering  her 
reason  she  has  recovered  her  modesty  and  self-restraint.  When 
the  human  mind  loses  some  of  the  divine  powers  bestowed  by 
its  Creator,  it  becomes  as  the  mind  of  a  brute.  Madness  is  not 
something  added  to  it,  but  something  taken  away;  those  powers 
are  taken  away  by  virtue  of  which  it  is  said  to  be  made  "in  the 
image  of  God,"  and  by  virtue  of  which  it  resists  degrading  in- 
fluences. The  degrees  or  forms  of  madness  are  degrees  of  loss 
of  free-will  and  self-control. 

I  am  happy  to  say  she  has  now  become  rational,  and  also  re- 
gained control  over  her  sphincters,  so  that  she  is  on  the  road 
towards  convalescence.  But  if  any  more  accidents  happen,  I 
will  bring  the  case  before  you  again. 

You  saw  that  till  the  inflamed,  or  dying  portion  of  skin  gave 
way  and  broke,   I   kept   it   carefully  painted  over   with   gutta 


TYPII-FEVER.  131 

perclia  dissolved  in  chloroform;  she  has  also  had  a  water-pillow. 
The  treatment  w^as  unsuccessful  indeed  in  this  instance,  but  still 
it  is  the  best.  'After  the  skin  was  broken,  a  cinchona  cataplasm 
was  applied,  which,  by-the-bye,  I  may  tell  you  how  to  prepare 
most  economically.  Do  not  make  it  entirely  of  bark,  but  sprinkle 
the  powder  thickly  over  a  common  bread  or  linseed  poultice; 
you  thus  save  an  expensive  drug,  and  also  keep  it  moister.  Now 
that  the  sloughy  cellular  tissue  has  separated  and  been  cast  off, 
I  shall  treat  the  sore  by  touching  it  alternately  with  nitrate  of 
silver  and  applying  tincture  of  benzoin,  whenever  the  edges  look 
livid  and  unhealthy. 

These  low  inflammations  in  continued  fever  are  almost  always 
a  reason  for  giving  alcohol  to  sustain  the  nervous  system.  Emily 
H —  had  at  first  six  ounces  of  port  wine  daily,  but  I  was  soon 
obliged  to  increase  her  allowance  to  half  a  bottle,  and  she  will 
probably  continue  that  during  a  great  part  of  her  convalescence. 
There  is  danger  in  suddenly  leaving  off  stimulants  which  have 
been  beirun  in  fever. 


{Clinical^  St.  Mary's^  January  24,  1863.) 

Elizabeth  J — ,  aged  nineteen,  came  in  on  January  16,  with 
rheumatic  fever,  affecting  principally  the  feet,  knees,  and  hands. 
There  was  one  day  considerable  pain  on  pressure  of  the  cardiac 
region,  such  as  is  caused  by  rheumatism  of  the  intercostal 
muscles;  but  that  was  immediately  relieved  by  the  application 
of  half  a  dozen  leeches,  and  there  were  no  symptoms  or  signs  of 
the  disease  spreading  to  the  heart  or  pericardium.  The  pains 
were  quite  gone  on  the  21st;  and  on  Sunday  the  25th  she  was 
up  and  dressed,  though  still  on  the  low  diet,  which  seems  best 
to  suit  convalescents  from  acute  rheumatism.  On  that  day  she 
was  taken  with  rigors,  sudden  loss  of  appetite,  severe  pains  in 
the  head,  in  the  back  and  limbs,  and  complete  prostration  of 
strength.  When  the  house-surgeon  saw  her  in  the  evening,  the 
tongue  was  exceedingly  clammy,  and  covered  with  a  whity-brown 
coat,  as  if  getting  dry;  she  was  delirious;  the  pulse  was  120; 


132  TYPII-FEVER. 

and  the  skin  hot,  and  of  a  dusky  mottled  color.  Now,  these 
symptoms  were  certainly  not  caused  by  the  alkaline  treatment 
of  the  rheumatic  fever,  for  she  took  the  bicarbonate  of  potash 
only  five  days,  was  not  prostrated  by  it,  and  had  left  it  off  for 
four  days;  but  as  there  had  been  a  constant  succession  of  bad 
cases  of  typhus  fever  in  the  ward,  and  the  patient  had  all  the 
symptoms  of  that  complaint,  Dr.  Rhodes  wisely  decided  that 
she  must  have  caught  it;  and  wisely  also,  acted  in  a  decided 
manner.  He  immediately  ordered  her  an  emetic,  and  after  its 
action,  the  usual  diet  and  hydrochloric  acid  every  two  hours, 
with  tepid  sponging  three  times  a  day. 

I  have  told  you  that  emetics  will  sometimes  extinguish  a  typh- 
fever  by  a  kind  of  conp-de-main.  But  really  the  cases  in  which 
this  fortunate  result  follows  are  so  rare,  that  you  might  hesitate 
whether  it  was  worth  aiming  at,  if  no  other  good  was  to  be  gained 
by  such  bold  treatment.  It  did  not  follow  to  the  patient  now 
Tinder  consideration ;  she  remained  delirious,  quietly  talking 
nonsense  about  various  things;  during  Monday  and  part  of 
Tuesday  her  tongue  got  dry,  although  cleared  by  the  treatment, 
and  the  pulse  kept  quick.  The  prostration  and  tremor  of  hands 
were  very  great.  It  was  impossible  not  to  conclude  that  she 
was  under  the  influence  of  a  powerful  poison.  The  cause  of  the 
disease  was  not  removed,  or  the  disease  extinguished. 

Yet,  though  not  extinguished,  it  was  certainly  shortened,  for 
on  Wednesday  you  saw  her  with  her  tongue  clean  and  moist, 
the  skin  much  cooler,  and  the  pulse,  though  still  120,  much 
firmer.  Now,  the  normal  duration  of  such  a  severe  typh-fever, 
as  she  gave  every  promise  of  having  to  go  through,  is  at  least 
three  weeks;  and  she  would  have  had,  in  the  course  of  nature, 
to  be  much  worse  before  she  was  better.  But  here  you  see  her 
in  three  days  enter  upon  a  convalescence  which  I  do  not  doubt 
will  be  permanent;  and  I  cannot  help  attributing  this  abbrevia- 
tion of  the  malady  to  the  emetic. 

She  was  so  much  better  on  Wednesday,  that  I  was  asked  if 
she  should  leave  off  the  acid  and  be  put  upon  the  bark  treatment 
of  convalescence,  and  also  whether  she  should  have  wine.  I 
have  never  made  the  alteration  of  medicine  so  early  in  the  dis- 


TYPII-FEVER.  133 

ease  as  this;  but  I  have  occasionally  been  induced  by  the  clean- 
ness of  the  tongue  to  do  so  only  a  few  days  later.  And  I  must 
say,  I  have  usually  seen  reason  to  regret  it.  The  too  early  ad- 
ministration of  cinchona,  as  well  as  tlie  too  early  administration 
of  solid  food,  have  appeared  to  me  to  have  been  the  causes  of 
relapse  in  several  cases.  It  is  better  not  to  give  cinchona  at 
all,  and  to  postpone  solid  food  till  the  patient  is  quite  strong 
again,  tlian  to  give  them  imprudently  soon,  and  so  to  run  the 
risk  of  relapse. 

As  to  wine,  seeing  that  she  is  a  young  girl  not  habituated  to 
alcohol,  and  has  got  over  her  delirium  without  it,  I  think  it  a 
superfluous  expense. 


LECTURE   X. 
SMALLPOX. 

Part  I. — Case  of  smallpox  watched  from  first  infection — Se- 
quence of  phenomena — Memoria  technica  by  which  to  remem- 
ber their  order — Use  of  observing  the  order — Action  of  oxygen 
on  tlie general  health  of  the  patient  and  on  the  skin  contrasted — 
3Iicroscopical  examination  of  the  contents  of  the  pocks.,  ivith 
practical  deductions  therefrom — Depth  of  injury  to  skin  in 
smallpox — Reasons  for  cutting  the  hair. 

Part  II. — Sj^read  of  smcdlpox  in  the  hospital  from  the  above 
case — Example  of  the  use  of  vaccination  in  modifying  the  dis- 
ease— Action  of  vaccinia  not  homceopathic  or  counter-irritant — 
Infectiousness  of  smallpox  compared  zvith  other  diseases — Dif- 
ferent degrees  of  infectiousness  demand  different  precautions. 

[Cliiiiccd,  St.  Mary's,  January  16,  1863.) 

You  have  had  a  chance,  such  as  falls  to  the  lot  of  only  lucky 
medical  students,  of  watching  the  whole  progress  of  a  case  of 
smallpox,  from  the  first  introduction  of  the  poison  into  the  body 
up  to  the  completion  of  its  work,  in  a  young  woman  about  whom 
I  lectured  last  week  apropos  of  her  previous  attack  of  typh-fever.* 
On  December  18,  Sarah  II —  was  confined  to  her  bed  in  the 
long  ward,  when  a  patient  with  variolous  eruption  fully  developed 
was  brought  in,  the  law  excluding  such  cases  having  been  broken 
by  an  oversight  consequent  on  the  occupation  of  the  officials  at 
a  hospital  election.  This  person  remained  scarce  two  hours  in 
the  ward,  and  was  never  nearer  to  Sarah  H —  than  thirty-six 
feet.  But  an  extra  nurse,  who  was  then  engaged,  may  very 
likely  have  been  in  attendance  on  both,  and  have  carried  the 

*  See  page  122. 


SMALLPOX.  135 

infection  in  her  clothes,  not  having  been  reserved,  as  she  ought 
to  have  been,  to  the  dangerous  patient.  That  such  a  mode  of 
transfer  may  have  taken  place  is  rendered  probable  by  this  nurse 
having  communicated  smallpox  to  her  own  child,  with  whom  she 
slept,  without  taking  it  herself.  The  nurse,  however,  and  all  in 
the  ward  except  Sarah  H — ,  had  been  fully  vaccinated;  and  it 
shows  the  powerful  protection  thus  afforded,  that  all  escaped 
personal  harm  except  Sarah  H — .  On  her,  indeed,  vaccination 
had  been  performed,  but  it  had  failed. 

Here  you  have  been  enabled  to  fix  the  exact  time  when  the 
poison  was  received,  and  to  trace  the  history  of  the  resulting 
disease,  unmodified  by  any  protecting  or  disturbing  causes.  The 
pathology  of  smallpox,  as  we  are  taught  it  in  books  of  syste- 
matic medicine,  is  derived  from  such  examples  as  these,  occur- 
ring in  the  olden  time  before  it  was  neutralized  by  Jenner's 
immortal  discovery.  And  it  should  give  us  confidence  in  our 
forefathers'  powers  of  observation  that  cases  of  unmodified  small- 
pox, then  the  rule,  now  happily  the  rare  exception,  are  rightly 
described.  You  have  seen  a  sequence  of  phenomena  punctual  to 
the  due  times  laid  down  by  them,  and  which  I  teach  you  in  my 
systematic  lectures  on  their  authority.  Twelve  days  did  the 
seed  lie  dormant ;  then  its  presence  w^as  declared  by  a  three  days, 
a  more  properly  two  days  and  a  half,  fever  (counting  from  the 
first  rigor) ;  then  for  two  days  it  bore  a  crop  of  papules ;  after 
that,  a  vesicle  growing  gradually  opaque  for  three  days  more, 
and  then  for  two  days  encircled  by  a  halo  of  rosy  inflammation  ; 
the  next  night  brought  the  evidence  of  the  complete  filling  of 
most  of  the  pustules,  by  the  rupture  of  the  little  band  of  epider- 
mis which  had  hitherto  fastened  their  centers  to  the  cutis.  When 
the  vesicles  were  two  days  old,  the  face  swelled  and  there  was 
considerable  salivary  secretion ;  and  the  distention  of  the  pustule 
was  accompanied  by  swelled  extremities.  Since  then  the  erup- 
tion has  been  gradually  drying  up. 

This  normal  order  of  the  phenomena  of  variola  is  important  to 
remember,  not  merely  because  it  is  a  matter  of  scientific  inter- 
est, but  that  you  may  be  able  to  satisfy  yourselves  and  your 
patients  that  all  is  going  on  right,  and  that  the  very  disagree- 


136  SMALLPOX. 

nble  and  painful  appearances  which  they  present  are  not  signs 
of  overhanging  danger.  I  refer  especially  to  tlie  swelling  of  the 
face  and  hands  occurring  in  proper  succession,  and  Avhich  would 
be  alarming  if  unexpected  ;  whereas  if  you  are  enabled  to  forsee 
them,  they  are  rather  good  omens  than  the  contrary,  and  a 
source  of  justifiable  consolation. 

To  assist  my  memory  as  a  pupil,  I  put  the  facts  into  some 
doggrel  Latin  verses : 

Bis  sex  celatur  virus,  tres  febre  notatur, 
Fertque  duos  soles  papulam.  tres  postea  opaquam 
Vesicam,  roseuraque  duos  perfectior  orbem  ; 
Vincla  cutis  niedii  dissolvit  postera  luna. 
Bidua  vultum  inflat  vesica,  movetque  salivara. 
Pustula  fert  distenta  manumque  pedumque  tumorem. 

Rough  and  bad  as  they  are,  they  served  my  purpose.  You  may 
easily  fix  them  in  your  minds  by  taking  the  trouble  to  make  im- 
provements in  the  versification,  for  which  there  is  ample  room. 
There  will  be  a  real  clinical  use  in  such  an  exertion  of  school-boy 
knack. 

The  unvarying  sequence  of  the  symptoms  in  smallpox  may 
also  serve  in  doubtful  cases  as  a  means  of  diagnosis,  not  only 
from  other  eruptive  fevers,  but  even  from  chronic  diseases.  I 
have  known,  for  instance,  a  case  of  eruption  in  a  baby  at  the 
breast,  Avhere  it  was  impossible  to  decide,  by  the  appearance, 
whether  it  was  variolus  or  syphilitic,  and  where  the  counting  of 
the  days  alone  enabled  a  conclusion,  afterwards  proved  correct, 
to  be  come  to.  I  think  I  see  you  smile  at  the  idea  of  two  such 
different  diseases  as  syphilis  and  smallpox  being  confounded.  But 
your  smile  is  one  of  imperfect  experience.  Syphilis,  child  of 
sin,  shows  its  kinship  to  the  father  of  lies  by  imposing  upon  us 
with  imitations  of  many  an  innocent  morbid  state ;  and  among 
the  rest  it  will  often,  in  the  infant,  assume  the  exact  aspect  of 
smallpox,  with  central  depression,  red  halo,  and  other  usual  diag- 
nostic marks.  The  reckoning  of  the  days  of  latency  and  the 
history  of  the  progress  of  eruption  will  alone  save  you  frcfm  fall- 
injr  into  our  forefathers'  error  of  confounding  the  "small"  and 
the  "great"  pocks  in  babies,  as  the  nomenclature  shows  that 
they  did  in  early  days. 


SMALLPOX.  137 

You  may  have  observed  that  this  woman  was  placed  in  a  large 
room  by  herself,  with  a  blazing  fire  and  two  windows  open  night 
and  day.  To  this  access  of  fresh  air  to  the  lungs  a  great  part 
of  her  freedom  from  the  unfavorable  symptoms  so  often  accom- 
panying confluent  smallpox  is  doubtless  to  be  attributed.  She 
has  enjoyed  her  liquid  food  all  along,  and  has  several  times 
prompted  the  addition  of  eggs,  pudding,  ale,  &c.,  to  her  diet 
card,  and  I  have  no  doubt  will  ask  for  solid  meat  as  soon  as  the 
sore  pustules  in  her  throat  will  allow  her  to  swallow  it. 

But  though  the  copious  access  of  oxygen  to  the  lungs  is  so 
highly  desirable,  I  question  very  much  whether  it  is  equally  de- 
sirable to  the  skin.  I  am  led  to  this  doubt  by  the  following  ob- 
servation. When  the  pocks  were  filled  out,  I  opened  a  good 
many  with  a  lancet,  and  examined  under  a  microscope  the  con- 
tained matter.     This  was  divisible  into  three  classes  : 

1.  That  taken  from  pocks  of  small  size  and  with  slight  inflam- 
matory halo.  It  was  of  the  consistency  of  thin  lard,  white  and 
opaque.  Microscopically  examined,  it  was  seen  to  consist  en- 
tirely of  epidermic  scales,  the  majority  among  them  of  normal 
aspect,  but  some  filled  with  granular  matter  hiding  from  view  the 
usual  nucleus. 

2.  That  taken  from  distinct  and  non-confluent  pocks,  with  a 
broad  halo,  but  not  the  largest  or  most  humid  of  their  kind. 
Here  the  normal  scales  Avere  few,  the  granular  scales  equalling 
them  in  number,  but  more  numerous  than  either  were  pus-glo- 
bules of  various  sizes  and  of  irregular  shapes,  as  if  budding  on 
several  sides. 

3.  That  taken  from  the  worst  of  the  distinct  pocks  and  from 
the  confluent  parts.  This  consisted  in  several  specimens  entirely 
of  equal  sized  pus-globules,  with  many  dark  specks  and  highly 
refractive  fat-globules  among  them.  There  were  hardly  any 
epi<lermic  scales  visible. 

Three  grades  of  death  in  the  skin  are  represented  by  these 
three  classes.  In  the  first,  the  growing  epidermis  is  merely 
loosened  and  thrown  off"  in  a  pasty  state;  in  the  second,  the 
cells  are  destroyed  at  an  earlier  stage  of  their  existence,  and 
only  partially  acquire  a  right  to  be  called  scales  at  all ;  in  the 


133  SMALLPOX. 

third,  they  are  killed  still  earlier,  and  their  constituents  form 
new  pus. 

By  the  last  condition  certainly,  and  by  the  second  possibly, 
the  cutis  runs  great  danger  of  being  permanently  scarred.  Any 
accidental  rubbing  or  disturbance  must  risk  the  causinor  it  to 
ulcerate,  and  thus  to  form  a  pitted  cicatrix.  It  is  therefore  of 
great  consequence  to  the  future  appearance  of  the  patients,  if 
not  to  their  freedom  from  consecutive  fever,  that  the  pocks 
should  be  kept  from  assuming  such  a  condition.  Now,  on  look- 
ing over  the  person  of  this  woman,  I  found  it  to  be  a  rule  that 
the  grade  of  destruction  bore  a  direct  ratio  to  the  exposure  of 
the  various  parts  to  the  air.  The  most  favored  situations  were 
the  thighs,  tongue,  and  abdomen,  next  the  legs  and  back,  and 
then  the  hands  and  forearm.  The  face  was  the  most  purulently 
affected  of  all.  With  regard  to  the  back,  I  should  observe  that 
it  maintained  its  comparative  immunity  from  advanced  inflam- 
mation in  spite  of  the  cuticle  being  much  chafed  and  rubbed  off 
in  large  patches  by  the  movement  of  the  patient.  So  it  would 
seem  that  oxygen  and  evaporation,  so  beneficial  to  the  healthy 
skin,  are  death  to  it  when  diseased,  and  that  the  best  hope  of 
preventing  its  destruction  in  smallpox  is  to  defend  it  from  these 
agents. 

To  assist,  then,  the  restoration  of  the  skin,  in  parts  important 
to  the  appearance,  I  believe  it  to  be  a  most  reasonable  practice 
to  cover  it  over  with  a  coating,  as  impermeable  as  can  be,  of 
collodion  or  solution  of  gutta  percha.*  This  can  be  easily  done 
on  the  nose,  cheeks,  forehead,  and  ears,  without  interference 
■with  motion,  and  the  coating  itself  and  the  rest  of  the  face  may 
be  thickly  oiled.  It  is  only  the  most  staunch  adherents  of 
therapeusis  by  evacuation  that  could  object  to  this  practice. 
Another  rather  more  antiquated  plan  is  to  puncture  the  vesicles 
directly  they  are  fully  formed.  The  same  object  is  aimed  at, 
namely,  the  prevention  of  ulceration  in  the  skin,  and  it  is  usually 
attained.     But  this  latter  expedient  is  rather  troublesome,  as  it 

*  Dr.  Smart  has  found  that  a  solutioa  of  caoutchouc  applied  iu  the  same 
way  is  better  ;  he  says  it  is  elastic,  and  does  not  crack  and  peel  ofiF,  like  gutta 
percha. 


SMALLPOX.  139 

runs  a  chance  of  being  roughly  and  coarsely  executed  if  left  to 
a  nurse. 

The  depth  to  which  the  cutis  is  injured  by  the  more  severely 
inflamed  of  the  pocks  is  curiously  exemplified  in  the  case  of  a 
young  woman  readmitted  to-day  with  valvular  disease  of  the 
heart  (Eliza  M — .  Folio  169,  p.  20).  Her  face  is  seamed  and 
graven  over  with  white  cicatrices,  the  relics  of  a  variola  by  which 
she  was  affected  years  ago.  The  cicatrices  are  made  more  than 
commonly  conspicuous  by  the  extreme  venous  congestion  of  the 
rest  of  the  skin  of  the  face  dependent  upon  her  cardiac  lesion. 
This  venous  congestion  Avas  so  livid  (almost  black),  that  I  should 
have  been  very  much  alarmed  about  it,  as  significative  of  a 
dangerous  disturbance  of  the  circulation,  had  I  not  remembered 
her  as  an  old  patient,  and  been  familiar  with  her  scarred  face. 
By  experience  I  knew  that  a  moderate  amount  of  dyspnoea  was 
accompanied  in  her  case  with  extreme  congestion  of  the  capil- 
laries of  the  delapidated  skin.  This  may  serve  as  a  lesson  to  you 
not  to  be  too  soon  frightened  at  the  venous  blueness  of  the  coun- 
tenance in  pock-marked  patients. 

You  may  have  observed  that  the  smallpoxed  patient's  hair 
has  been  cut  short  with  scissors,  leaving  it  about  half  an  inch 
long  all  over.  The  object  of  this  is  partly  cleanliness,  for  it  is 
impossible  to  keep  long  hair  from  being  saturated  with  the  dis- 
charge from  the  pocks,  and  then  it  becomes  most  fetid.  The 
scalp  is  so  sore,  from  being  covered  with  the  eruption,  that  brush- 
ing, or  combing,  or  washing  is  barely  possible.  Besides  which 
the  hairs  are  so  much  loosened  by  the  purulent  condition  of  the 
skin,  that  they  are  easily  dragged  out  in  handfuls,  almost  by  their 
own  weight,  if  long.  This  forcible  dragging  out  injures  the  hair- 
bulbs,  so  that  they  will  not  sprout  again.  And  it  also  still  fur- 
ther inflames  the  scalp.  So  that  the  best  chance  for  saving  the 
hair  is  to  cut  it  short,  since  shaving  the  head  is  out  of  the  ques- 
tion from  the  pain  it  would  give. 

{Clinical,  St.  Mary's,  Fehruai-y  5,  1863.) 

An  order  from  the  weekly  board  to  empty  the  beds  and  clear 
the  wards,  on  account  of  the  late  spread  of  smallpox  among  our 


140  SMALLPOX, 

inmates,  leaves  me  no  patients  to  lecture  upon,  so  I  will  make  a 
virtue  of  necessity  and  give  you  a  few  more  remarks  on  the  cause 
of  this  misfortune. 

Since  I  took  variola  as  my  text  three  weeks  ago,  seven  more 
persons  have  contracted  it  within  our  walls.  They  have  had  it 
in  various  degrees,  and  two  have  died.  But  as  none  of  them 
have  been  under  my  charge,  I  have  not  their  symptoms  to  com- 
ment upon.  Among  the  seven  was  one  of  yourselves,  a  house- 
surgeon,  who  had  prudently  revaccinated  himself  when  he  found 
the  disease  was  spreading.  While  the  vaccine  pustule  was 
forming,  he  found  his  body  overspread  with  an  erythematous 
blush,  which  he  thought  at  first  to  be  scarlatina,  but  it  soon 
showed  itself  to  be  only  the  forerunner  of  a  variolous  eruption. 
This  precautionary  vaccination  was  not  then  completely  success- 
ful. But  his  attack  of  smallpox  has  been  very  slight,  it  has  not 
confined  him  to  bed,  and  the  few  scattered  pustules  are  dying 
oif  without  causing  any  inflammation  of  the  skin.  The  protect- 
ion, tliough  not  complete,  was  probably  still  useful. 

To  be  of  use,  the  poisoning  by  vaccinia  must  precede  that  by 
variola.  The  eruption  of  the  first  must  be  formed  before  the 
fever  of  the  second  comes  on.  This  is  not  my  own  observation, 
but  derived  from  the  experience  of  Dr.  Munk,  the  accomplished 
physician  to  the  Smallpox  Hospital,  and  it  is  what  one  would  a 
priori  have  expected. 

You  must  be  careful  not  to  look  upon  vaccination  as  in  any 
way  antidotal  or  remedial  to  smallpox.  It  is  not  a  case  of  a 
smaller  and  slighter  disease  curing  a  severer  one  already  exist- 
ing ;  otherwise  it  might  perhaps  be  taken  as  evidence  in  favor 
of  either  the  homoeopathic  or  counter-irritant  theories.  It  does 
not  cure  it,  or  even  modify  it  when  already  existing.  The 
rational  view  of  the  relation  of  the  two  is  this :  there  exists  in 
the  living  body  a  certain  unknown  constituent,  which,  coming 
into  contact  with  the  virus  of  vaccinia  or  variola  respectively,  is 
capable  of  being  converted  gradually  into  that  virus,  just  as 
surely  as  a  thousand  hogsheads  of  malt  sugar  may  be  converted 
into  alcohol  by  an  ounce  of  yeast.  But  when  it  has  once  been 
thus  converted  and  passed  away,  there  remains  nothing  for  the 


SMALLPOX.  141 

virus  to  act  upon,  and  it  is  consequently  harmless.  Vaccinat- 
ing a  child  is  an  act  done  on  the  same  principle  as  cutting  off 
the  dew-claw  from  a  puppy,  lest  it  should  lead  to  inconvenience 
in  after-life.  We  exhaust  or  obliterate  a  useless  substance  which 
might  lead  to  evil.  To  call  it  a  remedy  in  the  sense  in  which 
medicines  must  be  remedies  for  disease,  is  like  calling  the  re- 
moval of  the  dew-claw  a  cure  for  a  torn  leg,  or  to  talk  of  put- 
ting out  a  conflagration  by  previously  removing  the  inflammable 
furniture.  Prevention  is  not  cure,  however  much  better  it  may 
be. 

It  is  obvious  that  the  modification  of  diseases  on  the  same 
principle  as  vaccination  is  applicable  only  to  those  Avhich  occur 
but  once  in  life.  But  there  is  no  reason  for  the  world  to  despair 
of  seeing  scarlet-fever  and  measles  rendered  as  rare,  at  least,  as 
smallpox,  by  some  analogous  means.  Any  plan  which  offeis  a 
reasonable  chance  of  success  will  not  now  find  skeptics  to  oppose 
it  before  trial  in  the  ranks  of  our  profession. 

The  way  in  which  the  smallpox  has  spread,  in  spite  of  our 
efforts  at  quarantine,  shows  you  how  very  infectious  its  nature 
is — how  much  more  infectious  than  scarlet-fever,  measles,  ery- 
sipelas, or  typh-fever.*     I  have  placed  them   in  the  order  in 

*  I  had  a  striking  instance  a  few  months  ago  of  the  almost  incredible  con- 
tagiousness of  smallpox.  A  lady  about  to  be  confined  summoned  her  monthly 
nurse  on  October  29;  on  November  1  her  child  was  born;  on  November  12  an 
eruption  of  smallpox  appeared  on  it,  and  went  mildly  and  regularly  through 
its  regular  stages,  affecting  the  child'?  health  very  slightly.  The  interest  of  the 
case  lay  in  tracing  the  history  of  infection ;  for  it  is  obvious  that,  allowing  two 
days'  fever  and  twelve  days'  latency,  which  are  invariable  in  an  unprotected 
person,  the  virus  must  have  been  communicated  two  days  before  birth.  Every 
one  who  had  been  in  the  house  positively  denied  having  seen  anybody  affected 
with  the  disease,  and  the  mother  had  not  been  in  a  street  cab  for  weeks  pre- 
viously. At  last  it  was  discovered  that  after  the  monthly  nurse  had  left  her 
last  place,  the  child  she  had  been  bringing  up  sickened  with  smallpox  and  died, 
and  the  infection  was  traced  to  the  household  of  the  family  washerwoman,  whose 
daughter  had  been  laid  up  with  an  attack  so  mild  as  to  be  capable  of  conceal- 
ment. The  travels  of  the  virus  were,  then,  as  follows:  A  (the  washerwoman's 
daughter)  develops  it;  it  is  carried  in  the  clean  clothes  B  to  the  household  C, 
from  whence,  before  it  has  been  redeveloped  or  multiplied  by  the  child  who  died, 
it  is  carried  by  the  nurse  D  to  the  pregnant  lady  E;  E,  being  protected  by  vac- 
cination, does  not  exhibit  it,  but  passes  it  on  to  the  child  in  her  womb  F,  within 
10 


142  SMALLPOX. 

which,  in  my  judgment,  there  is  risk  of  communication  from  one 
person  to  another,  viz:  scarlet-fever,  measles,  erysipelas,  typh- 
fever.  Of  scarlet-fever  and  measles,  most  cases  arc  treated  at- 
home;  we  have  not  a  dozen  cases  of  each  in  the  wards  annually. 
Although  I  must  allow  that  a  good  many  instances  have  occurred 
of  scarlatina  spreading,  yet,  as  a  rule,  we  are  able  to  retain  the 
patients  in  the  general  wards  without  its  doing  so,  l)y  the  simple 
precaution  of  allowing  an  interval  of  eight  or  ten  feet  between 
the  scarlatinous  bed  and  the  next.  So  that,  without  expressing 
an  opinion  as  to  the  propriety  of  admitting  scarlatina  into  a 
general  hospital,  1  do  not  think  the  matter  of  sufficient  import- 
ance to  exclude  them  by  law.  Of  the  communication  of  ery- 
sipelas, again,  inost  of  you  during  your  pupilage  see  just  an 
instance  or  so  which  serve  to  illustrate  the  fact.  We  have  not 
enough  cases  in  the  wards  to  supply  many  examples.  But  of 
typh-fever  we  are  seldom  free,  seldom  indeed  are  we  long  with- 
out having  many  more  than  we  like  at  once.  Had  it  the  viru- 
lence of  smallpox,  which  of  the  patients,  which  of  the  physicians 
or  students,  unprotected  as  we  are,  could  possibly  escape?  Only 
an  occasional  rare  exception,  just  enough  to  prove  the  facts  by 
tradition  among  you,  occurs  of  its  being  contracted  in  the  hos- 
pital, I  can  recollect  only  three  instances  in  my  practice  of 
such  having  been  the  case. 

But  smallpox,  in  spite  of  the  protection  of  vaccination,  hardly 
ever  comes  among  us  without  leaving  a  virus  which  is  most  diffi- 
cult to  eradicate.  Each  time  that  a  patient  has  slept  a  night 
in  the  house  several  others  have  taken  it,  each  time  has  a  house- 
surgeon  been  infected,  and  we  have  got  rid  of  the  plague  only 
by  dint  of  clearing  the  wards,  whitewashing,  and  painting,  as 
we  are  now  doing. 

Being  infectious,  then,  is  not  an  absolute  quality  of  a  disease, 
requiring  some  one  and  absolute  means  of  prevention.  It  is 
comparative,   and  has  a  very   different  meaning  whether  it  is 

twenty-four  hours  after  she  first  saw  the  nurse  and  two  days  before  it  came  into 
the  world.  What  a  notion  this  gives  of  the  infinitesimal  subdivision  of  matter, 
and  also  of  the  powerful  protection  afforded  by  vaccination,  which  guarded  the 
mother's  body,  through  whom  the  virus  passed  without  the  slightest  injury. 


SMALLPOX.  143 

applied  to  smallpox,  or  to  yellow-fever,  or  to  scarlatina,  measles, 
typh-fever,  glanders,  syphilis,  itch,  &c.  The  means  need  to  be 
applied  in  ver_v  different  degrees  according  as  one  or  the  other 
of  these  complaints  are  to  be  provided  against. 

The  principle  indeed  involved  in  the  most  important  of  these 
measures  is  the  same;  it  is  dilution  of  the  virus  which  is  the 
cause  of  disease,  by  air  and  Avater,  before  it  can  come  in  contact 
"with  any  focus  of  increase,  that  is  to  say,  with  any  human  body. 
Chemical  "disinfectants"  (so  called)  are  useless,  unless  applied 
in  such  quantities  as  really  to  be  diluents;  and  being  useless, 
are  dangerous,  lest  they  should  be  trusted  to  and  exclude  the 
employment  of  the  really  efficient  agents.  If  you  advise  the 
use  of  them  at  ail,  select  the  most  disagreeable  in  odor,  that 
thus  the  servants  may  be  driven  to  dilute  the  poison  by  diluting 
the  disinfectant.  It  has  been  coarsely  but  truly  said  that 
chloride  of  lime  is  good,  for  "it  makes  such  a  stink,  that  you 
are  obliged  to  open  the  windows." 


LECTURE    XL 

R  H  E  U  M  A  T I  C    FEVER. 

Relations  of  the  practitioner  and  lecturer  to  rheumatic  fever — 
Description  of  treatment — (1)  Bedding — (2)  Fomentations — 
(3)  Remedial  agents — Bicarbonate  of  potash,  Iodide  of  potas- 
sium— (4)  Opium — (5)  Leeches — (6)  Poultices  in  pericarditis — 
(7)  Diet — Comme7itaries  on  the-restorative  agencies  of  the  afore- 
said treatment. 

{Clinical,  St.  31arys,  May  24,  1862.) 

Eheumatic  fever  is  a  pleasant  disease — I  mean  for  the  doctor 
to  treat,  though  not  for  the  patient  to  bear.  It  is  pleasant  for 
him  to  treat  it,  because  he  then  feels  himself  strong  and  useful. 
In  the  first  place  he  can,  by  the  judicious  exercise  of  his  art, 
insure  the  sufferers  against  several  perils  to  which  the  nature  of 
their  complaint  exposes  them.  Again,  he  can  save  them  much 
pain.  Thirdly,  he  can  shorten  the  otherwise  long  duration  both 
of  the  illness  and  of  the  convalescence.  Truly  in  most  diseases 
he  can  effect  one  or  other  of  these  objects,  but  in  none  I  think 
so  many  of  them,  so  surely  and  so  simply,  as  in  rheumatic  fever. 

Rheumatic  fever  is  also  a  pleasant  disease  to  lecture  about. 
It  presents  an  unusually  uniform  type,  so  that  the  short  descrip- 
tions you  have  had  in  the  systematic  course  of  lectures  on  the 
practice  of  medicine  are  found  really  applicable  at  the  bedside, 
without  the  necessity  for  guarding  them  with  all  sorts  of  excep- 
tions and  variations,  which  clinical  teachers  are  so  often  obliged 
to  resort  to  in  other  cases.  The  classification  I  adopt  points  to 
a  difi"erence  rather  of  degree  than  of  essence,  viz.,  "acute  rheu- 
matism," or  rheumatic  fever,  wliere  there  is  febrile  reaction, 
shown  by  furred  tongue,  &c.,  and  "subacute  rheumatism"  where 


RHEUMATIC  FEVER.  145 

there  is  none.  And  a  very  simple  uniform  treatment  may  be 
recommended,  which  hardly  ever  requires  modification.  So  that 
if  your  authority  with  your  patient  is  sufficient  to  enforce  due 
obedience  to  orders,  and  you  are  certain  of  your  diagnosis,  you 
need  have  but  little  anxiety  about  the  result. 

There  are  hardly  ever  absent  from  the  wards  specimens  of  the 
mode  of  treatment  I  adopt.  My  present  business  is  to  tell  you 
my  reasons  for  the  plan  pursued. 

But  first  let  me  speak  of  the  plan  itself. 

1.  The  patient's  bed  is  made  in  a  peculiar  fashion.  It  is  a 
standing  order  that  no  linen  is  to  touch  the  skin.  A  slight  calico 
shirt  or  shift  may  be  allowed;  but  if  the  patients  possess  under- 
-clothing  only  of  the  prohibited  sort,  they  are  better  naked.  Even 
a  linen  front  to  the  shirt  is  dangerous.  Sheets  are  removed, 
and  the  body  is  carefully  wrapped  up  in  blankets,  which  are  so 
arranged  as  to  shut  off  all  accidental  draughts  from  the  head. 
The  newest  and  fluffiest  blankets  that  can  be  got  are  used. 

The  bedclothes  being  put  so,  are  kept  so,  and  the  attendants 
and  students  are  warned  that  when  the  sounds  of  the  heart  are 
listened  to,  they  must  not  throw  ofi"  the  wrappings,  but  insert  a 
stethoscope  (first  warmed)  between  the  folds. 

2.  Those  joints  or  limbs  which  are  swollen,  red,  or  painful, 
are  wrapped  up  in  flannels  soaked  with  a  hot  fomentation  con- 
sisting sometimes  of  plain  water,  sometimes  of  decoction  of 
poppy-heads  with  half  an  ounce  of  carbonate  of  soda  to  each 
pint. 

3.  The  following  medicines  are  prescribed  with  a  curative  in- 
tention. 

(a)  If  the  skin  is  red,  swollen,  and  painful  about  the  joints — 
if  the  cellular  tissue  around  the  muscles  is  infiltrated  and  sensi- 
tive, so  that  motion  is  impossible  or  exquisitely  painful — more 
especially  if  these  phenomena  are  metastatic,  leaving  one  part 
free  and  attacking  another; — patients  have  then  the  "alkaline 
treatment"  pure  and  simple:  they  have  a  scruple  of  bicarbonate 
of  potash  in  camphor-water  every  other  hour,  night  and  day, 
when  awake. 

(b)  If  the  above  symptoms  are  insignificant,  and  the  pain  is 


146  RHEUMATIC  FEVER. 

felt  more  in  the  bones — if  it  is  intensified  rather  by  pressure 
than  by  motion — if  it  is  fixed  in  one  spot  and  not  metastatic; — 
then  I  add  two  grains  of  iodide  of  potassium  to  each  dose;  and 
directly  the  symptoms  have  taken  a  turn  towards  alleviation,  I 
leave  ofi"  the  alkali  altogether,  and  give  only  the  iodide  of  potas- 
sium. 

4.  Opium  is  given  in  exact  proportion  to  the  degree  of  sub- 
jective sensation  of  pain.  If  one  grain  be  not  enough  to  entice 
sleep,  a  grain  and  a  half  is  administered;  if  that  do  not  avail, 
two  grains.  Directly  the  pain  is  relieved,  the  quantity  is  dimin- 
ished. Nothing  efi"ects  the  desired  object  so  well  as  pure  opium 
in  pill  or  in  tincture. 

5.  If  the  pain  remain  fixed  in  one  joint,  instead  of  leaving  it 
as  it  leaves  other  places,  leeches  are  applied  there,  and  the  part 
is  kept  poulticed.  Sometimes  bruised  laurel  leaves  have  been 
mixed  with  the  poultice;  but  I  do  not  think  they  make  much 
difterence. 

6.  Leeches  and  poultices  are  also  applied  to  the  cardiac  region, 
if  the  heart  has  become  inflamed  either  inside  or  out.  The  pain 
felt  is  taken  as  an  indication  of  the  extent  to  which  the  leeching 
is  to  be  pushed,  so  soon  as  it  is  proved  by  auscultation  tliat  such 
pain  arises  from  inflammation  of  the  heart,  and  not  from  rheuma- 
tism of  the  pectoral  muscles.  The  constant  application  of  the 
poultice  is  made  imperative  after  the  leeches. 

7.  The  diet  is  varied  in  some  degree  accordino-  to  the  social 
and  personal  state  of  the  patients.  If  they  have  been  hearty, 
well-to-do  persons  before  the  attack,  they  will  bear  a  good  deal 
of  starvation,  and  are  accordingly  put  on  our  "simple  diet;"  to 
wit,  bread  and  butter,  gruel,  and  tea.  If  previously  they  have 
been  ill-nourished,  by  reason  either  of  ill-health  or  poverty,  or 
if  they  have  been  ill  for  some  time,  a  pint  of  broth  or  beef-tea 
is  added. 

I  will  now  go  on  to  comment  on  the  several  items  of  treatment 
in  the  order  in  which  I  have  placed  them. 

1.  Bedding. — It  is  impossible  to  make  too  much  account  of 
the  value  of  absolute  rest  and  an  evenly  high  temperature  to  the 
skin  in  rlicuuiatic  fever.      They  are  worth  all  the  other  means  of 


RHEUMATIC  FEVER.  147 

relief  put  together.  Since  I  have  succeeded  in  getting  our  nurses 
to  adopt  them  as  a  universal  rule  in  every  case  of  rheumatic 
fever,  without  exception,  I  have  had  hardly  any  patients  to  treat 
for  inflammation  of  the  heart.* 

The  rationale  of  the  action  of  warmth  is  very  simple.  Rheu- 
matic inflammation  is  an  injury  to  nutrition  which  is  entirely 
compensated  for  by  the  restored  function  on  return  to  health. 
Rheumatic  inflammation  passes  away  and  leaves  no  after  sign, 
no  wound,  no  scar.  This  only  happens,  however,  if  the  parts 
affected  are  kept  perfectly  still.  Should  duties  be  asked  of 
them  which  they  are  unable  to  perform  in  their  imperfect  con- 
dition— should  necessity  or  ignorance  lead  the  patient  to  keep 
moving  a  swollen  joint,  for  example — then  common  inflamma- 
tion is  superadded.  Then  the  pain  and  swelling  become  fixed, 
and  no  metastasis  can  take  place.  You  witness  this  fre([uently 
in  poor  working  people,  who,  through  need  or  ignorance  of  what 
is  likely  to  follow,  strive  to  go  on  with  their  business  up  to  the 
last  minute.  Laborers  come  into  the  hospital  with  the  disorder 
fixed  in  their  knees,  carpenters  in  their  elbows,  laundresses  in 
their  wrists;  so  that  you  may  make  a  shrewd  guess  at  their  trade 
from  the  part  where  the  disorganizing  inflammation  is  situated. 
Pain  may  be  cited  as  a  proof  of  beneficent  design  in  God's  laws 
as  shown  in  disease ;  it  is  a  warning  to  withhold  one's  self  from 
that  wdiich  evokes  it.  The  pain  of  rheumatism  is  a  call  to 
voluntary  absolute  rest.  Now,  in  the  joints  this  is  easily  ob- 
tained, and,  under  any  treatment  you  hardly  ever  see  disor- 
ganizing inflammation  begin  in  a  joint  after  a  patient  has  once 
taken  to  his  bed.  But  there  is  one  organ  whose  business  admits 
of  no  rest; — the  heart  must  needs  keep  beating  at  whatever 
cost: — and  the  heart  accordingly  is  well  known  to  be  fatally 
apt  to  be  struck  with  common  fibrinous  inflammation  at  all 
stages  of  rheumatic  fever.  Taking  a  lesson  from  what  I  have 
noticed  in  the  joints,  I  try  and  assist  the  heart  to  attain,  not  of 
course  the  Utopia  of  absolute  rest,  but  the  nearest  approach  to 
absolute  rest  that  is  within  the  bounds  of  possibility. 

Perhaps  you  may  think  the  object  would  be  gained  by  simple 

•"   On  this  point  see  tlie  stiUistics  ia  tlic  next  Lecture  but  one. 


148  RHEUMATIC  FEVER. 

confinement  to  bed  or  the  horizontal  posture.  It  is  not  so. 
Next  to  jumping  and  running,  there  is  nothing  gives  the  heart 
so  much  work  to  do  as  alternations  of  heat  and  cold.  Let  the 
physiologist  observe  the  healthy  organ,  let  the  physician  ex- 
amine it  in  a  state  of  disease,  and  they  will  find  that  a  change 
of  temperature  on  the  surface  of  the  body  is  followed  by  a  longer 
and  stronger  stroke  as  felt  by  the  finger,  by  a  longer  and  stronger 
sound  as  heard  by  the  ear  in  the  cardiac  region.  The  interval 
between  the  strokes  is  shortened;  and  thus  is  encroached  upon 
the  only  wink  of  sleep  the  hard-working  muscle  ever  indulges  in. 
What  does  the  accoucheur  do  who  wishes  to  apply  the  strongest 
vivifier  to  the  dormant  nerves  of  a  still-born  baby?  lie  dashes 
cold  water  and  cold  air  on  the  skin, — he  rubs  the  chest  dry  and 
applies  hot  cloths  apace, — again  he  dashes  it  with  cold, — making 
as  many  changes  as  he  can.  ^Yhat  the  accoucheur  is  so  anxious 
to  accomplish  there,  we  are  most  anxious  to  avoid  here;  and  I 
feel  sure  that  it  is  by  dint  of  screening  patients  with  rheumatic 
fever  from  the  influence  which  variations  of  heat  and  cold  have 
over  the  dependencies  of  the  pneumogastric  nerve  that  the  treat- 
ment now  advised  is  so  successful.  I  never  have  yet  had  peri- 
carditis come  on  when  it  is  once  fairly  begun  and  strictly  en- 
forced. 

I  scarcely  need  to  say  that  the  most  important  part  of  the 
person  as  respects  the  attainment  of  the  accoucheur's  object, 
and  our  opposite  object,  is  the  chest.  There  he  applies  his 
"stimulus,"  and  there  we  must  as  carefully  watch  against  it. 
A  patient  of  mine  at  this  hospital  (year  1859,  ISiO.  in  Reg.  711) 
got  pericarditis  by  being  dowsed  with  cold  water  on  the  face 
and  neck  for  an  hysteric  fit  accidentally  occurring  during  con- 
valescence from  rheumatic  fever.  And  as  a  student  I  used  to 
see  many  and  many  a  case  of  pericarditis  brought  on  by  the 
careless  way  in  which  the  thorax  was  bared  in  the  daily  stetho- 
scopic  examination.  It  is  doubtless  necessary  to  listen  to  the 
heart  thus  often,  in  order  to  convince  ourselves  of  the  absence 
of  morbid  sounds:  but  by  warming  the  stethoscope  in  our  pocket 
or  under  the  axilla,  and  making  the  blanket  into  a  tube  by  which 
to  insert  it,  we  reduce  the  risk  to  a  minimum,  and  avoid  deserving 
the  imputation  of  meddling  to  the  patient's  hurt. 


RHEUMATIC  FEVER.  14 <) 

I  spoke  just  now  of  the  importance  of  strictly  enforcing  tlic 
protection,  and  to  confirm  my  words  I  will  remind  you  of  nn 
instance  which  you  saw  a  fortnight  iigo  of  the  danger  of  the 
exposure  I  have  been  deprecating.  Margaret  K.,  aged  23,  was 
admitted  March  28  for  rheumatic  fever,  with  painful  swelling 
of  the  arms  and  legs;  from  this  she  recovered  perfectly  without 
any  affection  of  the  heart,  and  was  transferred  to  the  convalescent 
Avard.  On  April  17  she  had  a  relapse,  principally  affecting  the 
legs,  and  on  the  19th  I  found  her  in  bed  again.  By  an  over- 
sight she  had  not  been  blanketed,  and  when  I  felt  the  cold 
sheets  damp  with  the  patient's  perspiration  I  was  not  surprised 
that  slie  complained  of  constriction  across  the  chest.  You  heard 
me  rebuke  the  nurse  in  no  measured  terms,  and  prognosticate 
evil.  With  justice;  for  before  two  days  were  over  there  was  a 
melancholy  systolic  murmur  distinctly  audible.  I  trust  this  case 
has  been  a  warning  to  you;  and  I  can  assure  you  that  in  your 
private  practice  the  warning  is  most  necessary  to  be  remembered, 
so  careless  and  obstinate  are  people  in  carrying  out  the  doctor's 
orders.  I  make  it  a  rule  always  to  have  a  nurse  of  my  own 
selecting  in  a  case  of  rheumatic  fever. 

2.  Fomentations. — By  comparing  in  occasional  cases  one  limb 
wrapped  in  fomentations  of  simple  hot  water,  with  another 
where  decoction  of  poppy-heads  was  used,  I  have  fancied  that 
either  the  viscid  vegetable  matter,  or  the  small  quantity  of 
opium  in  the  poppy-heads,  contributed  towards  alleviating  the 
pain  a  little.  And  a  similar  experiment  has  led  me  to  the  same 
opinion  as  respects  an  alkaline  carbonate.  But  the  heat  is  the 
most  important  element  in  this  part  of  the  treatment.  Look 
well  after  your  nurse,  and  see  that  she  keeps  the  fomentation 
warm. 

3.  Curative  Medicines  [a). — With  unimportant  exceptions,  I 
have  treated  every  patient  for  the  last  seven  years  Avith  bicar- 
bonate of  potash,  having  evidence  of  its  power  to  shorten  and 
alleviate  the  disease  from  daily  experience  as  well  as  from  the 
statistical  deductions  of  Dr.  Garrod."^     In  a  great  majority  of 

*  It  will  be  seen  in  a  subsequent  lecture  (xiii  in  this  volume)  that  I  have  seen 
reason  to  hesitate  as  to  the  force  of  this  evidence. 


150  KIIEUxMATIC  FEVER. 

the  cases  very  rapid  relief  commences  ^vitll  the  commencement 
of  the  treatment,  and  continues  permanent.  But  in  a  certain 
number  no  effect  appears  to  be  produced,  sometimes  even  after 
the  urine  has  been  made  alkaline.  In  a  few  of  these  there  has 
been  committed  a  pardonable  error  of  diagnosis, — the  patient 
is  gouty.  In  a  few  we  are  deceived  by  gonorrhocal  rheumatism, 
a  disease  allied  to  pyaemia,  and  requiring  quite  different  man- 
affement.  Still  there  are  a  certain  number  of  instances  where 
true  rheumatic  inflammation  is  very  obstinate  and  does  not  yield 
to  the  alkaline  method.  And  in  these  you  will  find  the  peri- 
osteum and  pericondrium  afl'ected.  When  the  patient,  then, 
after  five  or  six  days  of  the  alkaline  treatment  is  no  better,  or 
but  little  better,  I  add,  as  I  told  you,  iodide  of  potassium  to  the 
potash,  and  in  a  few  days  more  continue  the  iodide  alone  during 
the  convalescence.  Of  course,  if  I  am  enabled  to  make  this 
condition  of  the  periosteum  out  at  the  first  visit,  I  begin  such 
treatment  forthwith. 

I  mentioned  just  now  that  I  had,  in  a  few  instances,  for  ex- 
ceptional reasons,  not  given  the  alkaline  treatment  for  rheumatic 
fever.  Among  those  are  included  a  middle-aged  laborer  and 
his  wife,  both  attacked  together  and  just  recovered,  in  which 
cases  you  saAv  no  medicine  given  during  the  acute  stage.  The 
object  of  this  omission  was  partly  to  test  a  suspicion  that  the 
alkalies  might  cause  or  augment  the  anaemia  and  weakness  so 
general  in  the  convalescence  of  rneumatic  fever,  or  perhaps 
might  give  rise  to  relapses  by  checking  the  course  of  the 
disease.  These  two  cases  did  much  to  disabuse  me  of  that  fear. 
We  saw  that  the  loss  of  flesh  and  strength  was  in  both  husband 
and  wife  as  great  as  usual,  if  not  greater  than  in  the  majority 
of  examples  which  come  before  us  in  the  wards — satisfying  us 
that  it  is  the  disease,  not  the  remedy,  which  is  to  blame  for  the 
usual  emaciation  and  weakness.  We  saw,  also,  that  one  of  the 
patients  (the  man)  had  a  relapse,  showing  that  to  nature  and 
not  to  art  is  to  be  attributed  this  unfortunate  occurrence  so 
frequent  in  rheumatic  cases. 

Partly  also  in  these  two  cases  I  wished  to  use  the  omission  as  a 
pretext  for  reminding  you  that  you  do  not  carry  in  your  medicine 


RHEUMATIC  FEVER.  151 

chests  any  absolute  or  indispensable  powers — to  sbow  you  that 
rheumatic  fever  is  a  state  in  which  the  forces  of  life  move  in  a 
circle,  in  a  road  which  leads  of  itself  back  towards  health — and  is 
not  a  chronic  disorganizing  process,  whose  path  may  be  drawn  as 
a  straight  line,  approaching  nearer  and  nearer  to  death  the  farther 
it  goes.  It  ends  of  its  own  accord,  or  at  all  events  without  the 
aid  of  art,  often  in  a  few  days,  often  (as  you  saw  here)  in  a  time 
quite  as  short  as  could  have  been  expected  had  medicines  been 
administered.  This  consideration  is  needful  to  enable  you  to 
rate  duly  the  value  of  numerical  arguments,  and  to  understand 
that  a  very  large  collection  of  cases,  much  larger  than  any  expe- 
rience in  private  practice  ever  can  supply  to  you,  is  needed  to 
prove  the  ability  of  medicines  to  shorten  rheumatic  fever.  If  you 
forget  this,  you  risk  being  misled  by  a  fallacy,  with  an  instance 
of  which  applied  to  experience  of  this  very  disease  I  was  amused 
a  few  years  ago.  I  had  an  interview  with  an  irregular  practi- 
tioner (very  irregular  indeed),  who  told  me  that  he  gave  no 
physic,  but  followed  "the  method  of  St.  James" — he  "annointed 
with  oil  them  that  were  sick,  and  the  Lord  raised  them  up."  As 
proof  of  the  success  of  his  plan  he  gave  me  the  history  of  two 
attacks  he  had  uiidergone  of  rheumatic  fever.  In  the  first  he 
was  treated  professionally',  and  was  laid  up  for  more  than  three 
weeks ;  in  the  second  he  obeyed  the  perversion  of  Scripture  above 
quoted,  and  was  out  of  bed  in  five  days.  Of  course  he  was  per- 
fectly impervious  to  argument. 

Do  not  misunderstand  my  words,  or  interpret  them  as  if  I 
intended  to  ridicule  the  proof  brought  by  Dr.  Garrod  of  the 
success  of  the  alkaline  treatment  in  shortening  the  average 
length  of  our  patients'  pains.  I  am  disposed  to  think  his  ob- 
servations prove  that  point,  though  they  do  not  show  that  the 
whole  duration  of  the  disease  is  less.  But  my  principal  reason 
for  adopting  alkalies  is  that  the  use  of  such  remedies  is  quite 
in  harmony  with  the  principles  of  restorative  medicine.  The 
deficiency  of  alkali  in  the  body  is  shown  in  all  quarters  by  the 
appearance  of  free  acids.  In  indubitable  cases  of  rheumatic 
fever  left  without  treatment  the  sweat  is  acid,  the  saliva  is  acid, 
the  urine,  instead  of  being  moderately  acid,  is  intensely  acid, 


152  RHEUMATIC  FEVER. 

the  breath  even  smells  acid.  The  blood,  indeed,  remains  alka- 
line, fortunately  for  the  life  of  the  patient,  but  that  is  only  done 
at  the  expense  of  becoming  exceedingly  watery,  and  producing 
the  ansemia  -which  is  so  characteristic  of  the  convalescence  of 
rheumatic  fever.  If  the  blood  is  aqueous,  and  contains  less 
solids  than  normal,  at  the  same  time  that  the  salts  bear  their 
usual  proportion  to  the  rest  of  the  solids,  it  is  obvious  that 
there  must  be  a  great  deficiency  of  those  salts  in  the  body. 
Though  the  blood  be  not  acid,  it  is  easy  to  understand  that  it 
carries  less  alkali  than  it  ought  to  do. 

A  real  deficiency  is  attempted  to  be  replaced  by  the  carbon- 
ated alkali.  An<l  when  we  think  how  great  is  the  mass  of  living 
matter  over  the  whole  of  which  this  great  deficiency  exists,  then 
is  explained  the  need  for  large  and  repeated  doses,  which  all 
good  observers  insist  upon.  To  give  a  few  grains  three  times  a 
day  is  mere  playing  at  healing,  and  cannot  be  reckoned  as  treat- 
ment at  all.  I  do  not  think  anything  less  than  half  an  ounce 
of  the  bicarbonate  of  potash  in  the  twenty-four  hours  can  be  of 
real  use.  Again,  if  this  run  off  straight  by  the  kidneys,  making 
the  urine  alkaline  too  quickly,  it  is  of  little  avail;  but  if  it 
mix  with  the  mass  of  the  corporeal  fluids,  and  be  some  time 
before  it  is  detected  by  its  alkaline  reaction  in  the  renal  secre- 
tion, the  good  effect  is  sensibly  felt  by  both  the  patient  and  his 
attendants. 

Again,  I  do  not  think  it  a  fair  trial  of  the  treatment  to  give 
the  potash  neutralized  by  an  acid,  as  a  tartrate  or  a  citrate. 
These  salts  may  be  good  for  rheumatism,  but  they  do  not  test 
Dr.  Garrod's  statistics.  And  similarly,  larger  doses  at  longer 
intervals  do  not  fulfill  the  indications. 

A  collateral  advantage  of  frequent  doses  is  the  more  attentive 
nursing  which  it  ensures.  In  these  of-repeated  visits  the  attend- 
ant looks  well  after  the  arrangement  of  the  bedding,  sees  that 
no  part  is  left  exposed  to  the  air,  and  as  our  naval  friends  say 
"makes  all  taught." 

(b)  The  employment  of  iodine  of  potassium  is  purely  empiri- 
cal. By  none  can  the  fact  be  explained  that  this  remarkable 
substance  restores  their  normal  functions  to  several  tissues — 


RHEUMATIC  FEVER.  I53 

most  notably  to  those  sparingly  supplied  with  blood-vessels,  such 
as  cartilaginous  and  white,  hard,  fibrous  parts,  the  periosteum, 
the  sheaths  of  tendons  and  of  nerves — and  even  influences  the 
hair,  the  nails,  and  the  outer  layers  of  skin.  Iodide  of  potas- 
sium is  of  signal  service  when  rheumatism  or  gout  attack  the 
tendons  or  the  thecae  enclosing  the  muscles  or  tendons.  I 
think  we  cannot  doubt  the  words  of  the  sufferers  when  they  say 
that  they  feel  the  better  for  it,  however  inexplicable  the  fact 
may  be. 

The  earlier  in  the  disease  that  iodide  of  potassium  can  be 
given  the  quicker  it  will  act.  You  may  see  this  in  syphilitic 
periostitis,  which  when  recent,  yields  rapidly,  and  when  of  long 
standing,  yields  but  slowly  to  the  influence  of  the  salt.  So  is 
it  in  rheumatism;  the  old  chronic  cases  are  aided  by  iodide  of 
potassium,  indeed,  but  prove  as  a  rule  very  obstinate  ;  while 
this  affection  of  the  Avhite  fibrous  tissues  Avhich  follows  rheumatic 
fever,  and  which  we  are  now  concerned- with,  is  usually  removed 
in  a  few  dnys,  because  it  is  taken  in  hand  at  an  early  period. 

4.  Opium. — This  is  given  purely  as  an  anaesthetic.  There  is 
no  reason  to  think  it  either  shortens  or  lengthens  the  time  the 
disease  lasts.  Curiously  enough,  it  does  not  usually  stop  the 
action  of  the  bowels  so  long  as  the  painful  condition  remains 
which  it  is  given  to  lighten.  Should  constipation  follow,  the 
inconvenience  is  easily  obviated  by  adding  two  or  three  grains  of 
good  extract  of  colocynth  to  the  opium  pill. 

5.  Bloodletting. — The  treatment  by  leeches  and  poultices  of 
the  common  inflammation  which  may  sometimes  over-ride  the 
rheumatic  in  joints  moved  about  during  their  weak  state,  has 
nothing  special  about  it.  It  may  generally  be  depended  upon 
to  prevent  disorganization,  because  in  point  of  fact  the  inflam- 
mation is  very  slight  and  diffused. 

6.  Carditis. — I  have  told  you  inflammation  of  the  heart  does 
not  come  on  in  patients  who  have  once  been  placed  and  kept 
under  the  treatment  detailed  to  you.  But  in  a  good  many  in- 
stances the  exposure  the  poor  people  have  been  subjected  to 
previously,  and  sometimes  tiie  necessary  time  spent  in  our  wait- 
ing-room, gives  you  an  unlucky  opportunity  of  seeing  me  treat 


154  RHEUMATIC  FEVER. 

this  complication.  If  it  is  found  out  ■within  twenty-four  hours  of 
coming  to  the  hospital,  it  is  of  course  registered  as  due  to  the 
circumstances  I  have  named,  and  our  nursing  is  not  to  be  hlamed 
for  it.  I  feel  satisfied  that  it  need  make  no  difference  in  the  ap- 
plicability of  the  alkaline  method  ;  indeed,  it  rather  strengthens 
my  resolution  to  insist  on  this  being  fully  carried  out.  It  de- 
termines me  also  to  be  more  than  usually  watchful  about  the 
maintenance  of  temperature  by  blankets,  and  to  take  care  of  the 
chest  in  special  by  continuous  poultices.  When  cardiac  symp- 
toms are  detected,  when  there  is  friction  or  a  murmur  detected 
by  the  ear,  or  even  when  pain  is  felt  on  pressure  of  that  vital 
part,  from  six  to  twelve  leeches  are  forthwith  applied  ;  these 
usually  relieve  the  pain  somewhat;  but  if  it  returns  again  next 
day,  they  are  to  be  repeated,  and  this  may  be  done  again  and 
again,  as  long  as  pain  lasts.  The  pain  is  the  best  measure  of 
the  acuteness  of  inflammation  in  serous  membranes;  and  so  long 
as  acute  inflammation  remains,  leeches  and  poultices  are  the  best 
remedies  for  it.*  To  mercury  I  have  never  been  able  to  trace 
any  advantage  at  this  stage ;  indeed,  I  am  not  sure  that  it  does 
not  dispose  to  pericarditis  by  increasing  the  proportion  of  fibrin 
to  the  other  constituents  of  the  blood.  Perhaps  after  effusion 
has  taken  place  it  may  be  useful,  but  I  am  not  quite  satisfied  that 
it  is  desirable  in  all  cases  even  then. 

Opium  may  be  given  in  full  doses  ;  and  far  from  being  contra- 
indicated  on  the  score  of  cardiac  inflammation,  it  is  all  the  more 
urgently  called  for.  For  it  certainly  does  control  and  loAver  the 
hurry  of  circulation  which  is  so  dangerous.  Under  its  use  the 
pulse  is  diminished  in  frequency,  sometimes  even  below  the  nor- 
mal standard;  and  this  must  surely  be  an  important  object  in 
a  diseased  state  brought  about  by  the  continuous  motion  of  the 
heart. 

The  treatment  of  pericarditis  brooks  no  delay.  Lost  minutes 
are  more  hurtful  here  than  in  any  disease  I  know  of.  Send  for 
leeches  and  have  thorn  applied  immediately  that  your  suspicions 
are  aroused  by  an  abnormal  murmur,  and  if  they  are  not  at  hand, 
cup  the  cardiac  region.     It  is  better  even  to  anticipate  evil  than 

*  This  subject  is  fuller  treated  ii»  a  subsequent  Lecture. 


RHEUMATIC  FEVER.  155 

to  be  too  late.  On  this  principle  you  saw  me  a  fortnight  ago 
leech  and  poultice  the  heart  of  the  young  woman  before  men- 
tioned (case  of  Margaret  K.),  where  you  could  hear  no  friction 
in  the  pericardium,  and  you  wondered  at  what  you  called  my 
"  sharp  practice."  But  the  fact  is,  it  was  a  case  of  relapse;  and 
as  the  patient  slept  in  the  convalescent  ward,  the  nurse  carelessly 
neglected  to  wrap  her  in  blankets :  the  cold  damp  linen  was  be- 
ginning to  do  its  work,  and  the  lengthened  heavy  stroke  of  the 
left  ventricle,  accompanied  by  a  sense  of  tightness  and  pain  on 
pressure,  Avarned  me  to  try  and  prevent  the  threatened  inflam- 
mation. I  was  only  partially  successful ;  the  forseen  evil  did 
come;  in  two  days'  time  an  exo-cardial  murmur  was  distinctly 
heard.  But  I  am  sure  the  pericarditis  was  in  a  much  milder 
form  than  it  would  have  been  had  leeches  not  been  applied. 

7.  Diet. — In  rheumatic  fever  there  is  a  painful  necessity  for 
restricting  the  supply  of  an  important  class  of  nutriment.  If 
meat  be  given,  it  seems  to  turn  into  lactic  acid,  at  all  events  it 
adds  to  the  quantity  of  organic  acids  in  the  body.  The  power 
of  fully  converting  it  into  living  flesh  is  wanting,  and  until  this 
power  is  i-estored,  a  semi-conversion  into  the  substance  named 
takes  place. 

Even  when  the  pains  are  gone  and  there  is  such  an  urgent 
call  for  replacing  lost  flesh,  the  most  suitable  diet  for  supplying 
it  Avill  sometimes  bring  on  a  relapse.  Hence  I  find  it  needful  to 
give  patients  less  food  than  their  feelings  prompt  them  to  take. 
The  redder  and  more  muscular  it  is,  the  more  it  seems  to  dis- 
agree, and  you  must  very  cautiously  get  back  to  "  ordinary  diet," 
else  you  run  a  risk  of  losing  more  by  a  second  attack  of  the 
disease  than  is  to  be  gained  by  haste.  Vegetable  matter  does 
not  expose  patients  to  the  same  danger,  and  thus  by  dint  of  rice 
pudding,  porridge,  gruel,  bread,  mashed  potatoes,  and  the  like, 
you  may  try  to  satisfy  the  mouths  which  often  loudly  complain 
of  starvation.  If,  however,  you  cannot  by  such  persuasion  suc- 
ceed in  staying  the  appetite,  it  is  your  duty  to  be  cruel,  for  ob- 
servation will  soon  convince  you  of  the  hurtful  eft'ects  of  animal 
food  in  causing  relapses. 


LECTURE   XII. 

RHEUMATIC    FEVER. 

Exceptional  cases  of  rlieumatic  fever — Inflammation  of  heart 
arrested  hy  epistazis — Delirium  and  gangrene  in  rheumatic 
fever — Treatment — Case  of  rheumatic  fever  in  a  tuhercidar 
subject,  with  consecutive  purpura  of  the  legs — Treatnietit  by 
lemon  juice. 

[Qlinical,  St.  Marys,  June  27,  1863.) 

A  YOUNG  woman  with  rlieuinatic  fever  in  the  corner  of  Vic- 
toria Ward  was  found  the  other  day  by  the  resident  medical 
officer,  Mr.  Mahon,  to  be  suffering  from  pain  in  the  cardiac  re- 
gion increased  by  firm  pressure.  Although  he  could  detect  no 
abnormal  sound  on  auscultation,  yet  he  thought  it  advisable  to 
order  half  a  dozen  leeches  to  be  applied  to  the  part.  He  was 
right  in  so  doing;  for  the  course  followed  by  inflammation  of 
the  heart  in  rheumatic  fever  is  this ; — first  the  rheumatism,  such 
as  you  see  it  and  feel  it  in  the  limbs  and  joints,  settles  in  the 
heart,  just  as  it  might  settle  in  any  other  part,  and  as  in  any 
other  part  without  common  or  disorganizing  inflammation  ; — but 
as  in  any  other  part,  motion  will  change  the  rheumatic  into  dis- 
organizing inflammation  ;  and  therefore  as  you  cannot  stop  the 
heart's  motion,  you  must  try  and  get  rid  of  the  rheumatism 
quickl}^,  and  for  the  time  only  perhaps,  but  at  any  rate  for  the 
time,  from  this  dangerous  locality.  And  you  must  not  mind 
making  some  sacrifice  to  accomplish  such  an  important  object. 
Now,  local  bloodletting  does  do  this  even  in  the  joints,  only  that 
it  is  not  in  general  worth  while  to  get  rid  of  the  rheumatism,  out 
of  the  knee  for  example,  when  in  half  an  hour  it  may  come  on 
just  as  bad  in  the  hand.     But  in  the  case  of  the  heart  it  is  worth 


RHEUMATIC  FEVER.  157 

while,  well  worth  while,  to  do  much  more  (if  wanted)  than  put- 
ting on  a  few  leeches. 

But  do  the  leeches  really  prevent  it  in  a  natural  and  physio- 
logical way  ?  See  the  answer  given  by  nature,  whose  silent 
speech,  though  unheard  by  those  who  will  not  listen,  is  as  a 
trumpet-call  to  the  attentive.  A  singular  accident  in  this  case 
has  shown  that  the  treatment  is  entirely  in  accordance  with 
reason  and  reasonable  physiology.  Though  ordered,  the  leeches 
Avere  not  put  on — and  why  ?  Because  in  the  meantime  the 
woman's  nose  burst  out  bleeding,  and  that  event  entirely  relieved 
the  pain  in  the  heart,  and  most  completely  justified  the  prescrip- 
tion which  had  been  written  by  rendering  it  unnecessary, 

I  do  not  want  you  to  accept  the  epistaxis  as  an  '*  effort  of 
nature,"  designed  to  relieve  threatened  carditis;  for,  as  a  matter 
of  fact,  any  idiopathic  hemorrhage  is  very  uncommon  under 
such  circumstances — but  as  a  fortunate  accident.  I  have  often 
given  you  my  reasons  for  not  acquiescing  in  the  theory  that 
morbid  phenomena  are  designed  for  the  promotion  of  physical 
health.*  If  it  has  any  design  at  all,  it  would  seem  designed  to 
teach  you  medicine ;  to  teach  you  that  a  very  moderate  loss  of 
blood  may  avert  a  great  danger. 

But  I  have  spoken  of  loss  of  blood  even  in  moderation  as  a 
sacrifice.  And  it  is  so  peculiarly  in  rheumatic  fever.  The  dis- 
ease is  one  which  cseteris  jJcci'ihus  attacks  the  weakest  persons  at 
their  weakest  times  ;  women,  children,  the  aged,  the  debilitated 
by  sickness  are  the  most  liable,  if  exposed  to  the  usual  causes. 
And  not  only  the  weakest  persons,  but  the  weakest  parts  of  those 
persons.  I  admitted  a  man  named  Amos  F.  into  Albert  Ward 
on  June  12  with  rheumatic  fever.  Two  years  ago  he  was  in 
this  hospital  for  paralysis  of  the  right  arm  and  leg,  in  conse- 
quence of  some  cerebral  lesion  probably,  and  he  has  never  re- 
covered full  power  in  the  upper  extremity.  Since  then  he  has 
had  rheumatic  fever  twice,  this  being  the  second  occasion,  and 
both  times  the  right  elbow  and  hand  have  been  the  place  first 
affected,  and  the  place  longest  and  worst  affected  both  with  pain 
and  swelling,  and  redness.      If  then,  rheumatic  fever  affects 

*  See  Lecture  I  and  L'Envoi,  for  the  Author's  views. 
11 


158  RHEUMATIC  FEVER. 

by  preference  the  weakest  flesh,  it  is  right  to  view  everything 
that  weakens  the  flesh  a  sacrifice.  In  that  light  we  must  con- 
sider loss  of  blood,  prudent  and  wise  though  the  sacrifice  may 
be. 


{Clinical,  St.  3Iari/s,  October  31,  1863.) 

Exceptional  cases  occur  seldomer  in  rheumatic  fever  than  in 
any  other  disease  I  can  at  this  moment  call  to  mind.  Yet  they 
do  occur  ;  and  there  is  now  in  the  wards  one  noteworthy  instance 
of  rare  symptoms  and  rare  treatment,  both  markedly  difierent 
from  what  I  have  described  as  those  of  at  least  ninety-nine  out 
of  a  hundred  of  the  patients  you  will  have  to  treat.  For  this 
hundredth  case  you  ought  to  be  prepared. 

The  fever  of  acute  rheumatism  almost  always  bears  the  type 
which  our  grandfathers  called  "synocha,"  and  our  fathers  "in- 
flammatory ;"  that  is  to  say,  the  relations  of  the  senses  and  the 
mind  are  not  impaired  in  the  direction  of  either  obtuseness, 
coma,  or  delirium  ;  there  is  no  tendency  to  the  local  death  of 
tissues  or  gangrene ;  and  the  congestions  which  may  intervene 
result  in  active  and  fibrinous  inflammation.  But  occasionally  it 
exhibits,  from  the  very  beginning,  the  character  of  typhus ;  the 
nervous  system  is  deeply  afi"ected  in  its  most  important  func- 
tions, there  is  an  excessive  depression  which  may  end  fatally, 
and  a  great  risk  also  of  slough  in  the  parts  compressed  by  the 
lying  posture. 

Such  are  the  peculiarities  in  the  case  of  George  R.,  received 
as  an  urgency  in  the  middle  of  last  week,  October  21.  He  is 
a  wiry  little  letter-carrier,  who  has  never  before  sufi"ered  from 
any  serious  illness,  and  is  only  twenty-four  years  old.  He  has 
a  happy  home,  and  a  merry  afi'ectionate  wife ;  is  active,  prosper- 
ous, and  intelligent,  employing  his  leisure  in  playing  the  organ 
at  a  neighboring  church.  I  recount  these  particulars  to  show 
that  his  antecedents  are  not  of  a  noxious  kind.  On  the  7th  of 
October  he  cleaned  out  a  dirty  cistern  and  got  very  wet  and  cold. 
On  the  9tli  he  felt  "out  of  sorts,"  and  took  a  hot  bath.     This 


RHEUMATIC  FEVER.  159 

exhausted  him,  and  he  also  got  chilled  in  coming  home.  Pains 
in  the  limbs  came  on,  and  on  the  11th  he  was  laid  up  in  bed 
with  increased  pain  accompanied  by  sAvelling  and  redness  in  the 
joints.  He  then  had  another  hot  bath,  after  which  he  was  still 
worse.  Ilis  wife  perceived  then  that  his  mind  began  to  wander 
from  time  to  time,  and  before  his  admission,  on  the  21st,  the  de- 
lirium was  constant  and  of  a  violent  character.  The  wrists, 
hands,  one  ankle,  and  the  other  knee,  were  red  and  much  swol- 
len, and  in  the  knee-joint  the  fluctuation  of  fluid  could  be  felt. 
But  during  his  ravings  he  moved  these  limbs  about,  seemingly 
regardless  of  the  pain  which  is  usually  so  acutely  felt  in  rheu- 
matic fever.  His  tongue  was  of  a  yellowish  brown  and  nearly 
dry,  the  lips  and  teeth  were  parched  and  brown  Avith  sordes.  The 
skin  was  sometimes  dry,  sometimes  bathed  in  a  profuse  sweat  of 
a  rancid,  sour  odor.  His  chest  was  covered  with  a  copious  erup- 
tion of  sudamina.  His  pulse  was  variable,  seldom  above  100, 
however.  His  bowels  were  constipated ;  but  after  a  dose  of 
castor  oil  they  were  normal  in  action.  A  stethoscopic  ex- 
amination of  the  chest  proved  the  heart  and  lungs  to  be  free  of 
any  inflammatory  lesion,  their  sounds  being  quite  healthy.  He 
became  so  noisy  and  violent  at  night  that  he  was  obliged  to  be 
moved  into  a  room  by  himself,  and  then  his  delirium  assumed  a 
more  rambling  form,  and  he  made  no  more  spasmodic  attempts 
to  get  out  of  his  blankets. 

I  saw  him  the  next  day,  the  22d,  and  ordered — I^  Opii,  gr.  j. 
omni  node.  I^  Potassii  lodicli,  gr.  xv;  Am7nonise  sesquicarb., 
gr.  iv;  Deaocti  cinchonse,  j.  4tis  horis.  iSix  ounces  of  jyort  wine 
daily,  and  a  cup  of  beef  tea  every  tivo  hours. 

His  delirium  and  low  typhous  symptoms  continued  till  the 
25th,  but  on  the  24th  he  was  suflSciently  quiet  to  be  moved  up 
into  the  ordinary  ward.  On  the  24th  the  spine  of  his  back  was 
noticed  to  be  red,  and  on  the  28th  it  is  noticed  in  the  case-book 
that  a  small  slough  had  formed  on  the  sacrum.  His  tongue 
however  had  got  quite  clean,  and  he  had  not  been  delirious  since 
the  25th.  The  pain,  swelling,  and  redness  had  all  disappeared 
at  that  date. 

Such  is  the  history  of  a  more  than  ordinarily  satisfactory  tei'- 


160  RHEUMATIC  FEVER. 

mination  of  typhous  rheumatic  fever.  I  have  seen  several  end 
fatally,  and  uas  at  first  very  anxious  about  this  young  man,  and 
was  all  the  more  anxious  from  some  ans'wers  he  gave  to  our  first 
questions  having  induced  a  notion  that  he  had  been  suffering 
recently  from  gonorrhoea;  and  I  thought  it  just  possible  that  we 
might  have  to  amend  our  diagnosis,  and  that  it  would  turn  out  a 
case  of  urethral  pyaemia  affecting  the  joints.  This  unAvorthy 
suspicion  was  however  taken  aAvay  by  the  indubitably  correct 
account  his  wife  was  able  to  give  of  his  freedom  from  that  dis- 
grace, and  by  his  own  assurance  when  he  recovered  his  senses. 

You  may  have  remarked  that  in  relating  his  history  I  impli- 
citly attributed  some  part  at  least  of  the  severity  of  the  disease 
to  the  hot-water  baths  taken.  Possibly  you  may  think  this  accu- 
sation of  mine  somewhat  inconsistent  witli  my  keeping  rheumatic 
fever  patients  in  a  sort  of  perpetual  warm  bath,  by  wrapping 
them  up  in  fomentations  and  blankets;  so  I  take  this  opportunity 
of  teaching  you  that  the  two  operations  are  not  only  essentially 
different,  but  essentially  contrasted  with  one  another.  A  hot- 
water  batli  involves  two  great  changes  of  temperature,  a  rapid 
one  from  the  original  heat  to  a  degree  above  the  original,  and 
a  slower  cooling  afterwards.  Packing  in  blankets  with  continu- 
ous fomentations  not  only  keeps  the  production  of  animal  heat 
■even,  but  it  also  defends  the  patient  against  external  variations. 
So  that  where  one  does  good,  we  may  reasonably  conclude  that 
the  other  does  harm. 

About  the  treatment  I  do  not  wish  to  say  much,  except  that 
it  was  in  the  highest  degree  stimulant  and  nutritious,  in  marked 
contrast  to  that  which  I  find  adapted  to  ordinary  cases  of  rheu- 
matic fever.  I  have  never  administered  iodide  of  potassium 
before  under  the  same  circumstances,  but  I  think  I  shall  again. 
Bark  and  ammonia  alone  I  have  given  on  former  occasions,  but 
not  with  equally  good  results. 

You  will  have  observed  that  my  first  act  on  hearing  the  his- 
tory was  to  apply  my  stethoscope  to  the  heart,  and  then  to  the 
lungs,  although  there  Avas  no  account  of  any  symptoms  refer- 
able to  those  viscera.  The  fact  is  that  delirium,  which  is  the 
secondary  result  of  pneumonia  or  pericarditis  in  rheumatic  fever, 


KHEUMATIC  FEVER.  161 

usually  masks  its  cause,  and  violent  inflammation  may  go  on  with- 
out showing  any  external  evidence  of  its  presence.  It  is  right 
therefore  to  look  for  these  local  inflammations,  for  in  point  of 
fact  delirium  of  such  an  origin  is  more  common  than  that  which 
we  see  here  with  lungs  and  heart  health}'. 

The  delirium  in  both  cases  I  believe  to  be  of  the  same  nature, 
to  be  in  itself  indicative  of  the  same  pathological  condition  of  the 
nervous  system,  and  to  be  suggestive  of  the  same  line  of  treat- 
ment, whether  it  exists  along  with  thoracic  inflammation  or  with- 
out thoracic  inflammation.  I  believe  it  indicates  a  threatening 
of  death  by  the  nervous  system,  which  must  be  warded  oif  as 
you  have  seen  it  warded  off"  here.  It  is  only  when  rheumatic 
pneumonia  and  pericarditis  have  gone  too  far  to  admit  of  deple- 
tory or  debilitant  measures,  or  occur  in  a  frame  already  disposed 
to  typhous  depression,  that  they  impair  the  cerebral  functions. 
When  therefore  delirium  supervenes,  I  would  advise  you  to  treat 
any  inflammation  of  tlie  heart  or  lungs  which  you  may  find  with 
it,  in  such  a  way  as  not  to  interfere  with  your  bark  and  your 
wine  and  your  opium. 

There  are  two  ways  in  Avhich  the  pathology  of  these  low  forms 
of  rheumatic  fever  may  be  explained. 

First,  it  is  not  impossible  that  a  zymotic  poison  may  enter  at 
the  same  time  with,  and  combine  to  form  a  new  compound  influ- 
ence Avitli  the  influences  which  originate  the  rheumatism.  And 
such  an  explanation  would  chime  in  very  well  with  the  history 
of  the  case  under  our  eyes;  for  the  man  says  his  illness  was 
caused  by  cleaning  out  a  foul  cistern,  where  decaying  organic 
matter  would  be  the  suitable  birthplace  of  febrile  malaria.  But 
I  have  not  been  able  to  trace  this  kind  of  evidence  in  other  in- 
stances. 

Secondly,  we  may  view  it  as  an  imitation  rather  than  as  the 
child  of  typh-poisoning.  The  symptoms  by  which  we  recognize 
the  action  of  that  virus  are  especially  exhibited  in  the  nervous 
functions — the  rigors,  the  languor,  the  delirium,  are  witnesses  of 
death  in  the  nerves — and  when  such  death  in  the  nerves  is  due 
to  other  causes,  the  same  symptoms  arise.  Hence  you  have  the 
low,  or  typhous,  state  arising  after  severe  injuries  of  all  kinds, 


1G2  RHEUMATIC  FEVER. 

when  the  destructive  consequences  of  those  injuries  arrive  at  the 
nervous  system.    This  may,  under  special  circumstances  of  which 
we  are  ignorant,  be  the  exceptional  case  in  rheumatic  fever. 
Neither  view  modifies  the  treatment. 


[Clinical^  St.  Mary's,  December  12,  1863.) 

In  Cambridge  Ward  is  an  example  of  rheumatic  fever,  which 
has  lain  in  the  hospital  longer  than  the  usual  time,  and  is  not 
yet  fit  to  be  discharged.  The  patient  is  a  carman;  John  H., 
aged  twenty-six,  admitted  November  7.  The  peculiarity  that 
distinguishes  it  from  the  ordinary  run  of  cases  is,  that  he  has 
consolidation,  detectible  by  bronchial  breathing,  and  presumably 
tubercular,  of  the  upper  lobes  of  both  lungs,  and  copious  muco- 
purulent secretion  from  the  bronchial  membrane  (chronic  bron- 
chitis) in  consequence  of  it.  Whenever  he  is  put  upon  low 
vegetable  diet  and  sweated  in  blankets,  his  rheumatic  pains  and 
swellings  of  the  ioints  subside  as  readilv  as  do  those  of  other 
patients ;  but  then  he  grows  terribly  weak,  and  the  expectoration 
increases  in  quantity  and  purulence,  so  that  we  have  to  give  him 
full  allowance  of  animal  food  and  quinine.  This  brings  back  the 
semi-acute  swellings  and  pains,  with  sour  rheumatic  odor  in  the 
sweat,  and  even  some  degree  of  fever.  Iodide  of  potassium  has 
not  prevented  these  relapses,  which  have  occurred  three  times. 

In  examining  his  legs  on  the  occasion  of  the  last  relapse,  I 
found  around  the  ankles  a  copious  crop  of  pin-head  specks  of 
purpura.  On  this  indication,  I  ordered  him  three  ounces  of 
lemon-juice  daily,  and  the  treatment  seems  to  succeed  very  well, 
for  he  is  gaining  strength  now  without  relapsing,  although  eat- 
ing meat  daily. 

Had  this  man  been  treated  by  alkalies,  it  is  most  likely  some 
of  us  would  have  attributed  his  purpura  to  that  cause.  But  the 
rheumatism,  in  its  acute  stage,  was  alleviated  only  by  the  usual 
blanketing  and  low  diet.  And  moreover  I  take  this  opportunity 
of  saying  that,  whatever  may  be  the  defects  of  the  alkaline  treat- 
ment (which  I  am  not  going  to  discuss  now),  the  production  of 


RHEUMATIC  FEVER.  103 

purpura  is  not  one  of  them.  I  have  not  seen  such  scorbutic 
condition  more  frequently  among  rheumatic  fever  patients  so 
treated,  than  among  others. 

This  seems  to  me  just  one  of  those  specially  circumstanced 
cases  of  rheumatic  fever  where  lemon-juice  is  suitable,  and  I 
think  that  it  was  from  the  obvious  advantage  derived  from  it  in 
similar  instances  that  its  credit  as  a  remedy  has  been  gained. 

The  difficulty  of  trimming  the  dietary  where  one  complaint  is 
to  be  benefited  by  starvation  and  another  by  high  feeding  is 
very  great,  and  it  is  a  most  fortunate  circumstance  that  this 
combination  is  rare  in  the  case  of  rheumatic  fever,  which  seldom 
occurs  in  consumptive  persons. 


LECTURE    XIII. 
KHEUMATIC    FEYER. 

THEKAPEUTICAL    STATISTICS. 

[Clinical,  St.  Marys,  January  9,  1864.) 

Statistics,  like  many  other  excellent  things  and  people,  are 
apt  to  prolong  themselves  into  bores,  and  in  so  doing  lose  much 
of  their  legitimate  force.  It  will  be  my  aim  therefore  to  make 
this  lecture  as  short  as  I  can. 

Between  June,  1851,  and  Christmas,  1863,  there  have  been 
in  the  wards  under  my  care  at  St.  Mary's  257  cases  of  rheumatic 
fever.  Of  these  (cases  still  remaining  under  treatment  on 
Christmas  day  not  being  included) — 

26  were  treated  with  5j  of  niter  three  times  a  day ; — 
174  were  treated  with  bicarbonate  of  potash — viz., 
141  with  3j,  or  more,  every  two  hours; — 
33  with  a  less  quantity; — 
32  were  treated,  during  the  first  year,  in  various  other  ways ; — 
25  (that  is  to  say,  all  since  May  last)  have  had  none  of  these 
supposed  curative  drugs;*  only  a  little  opium  when  the 
pain  was  very  severe,  and  a  purgative  when  the  bowels 
were  too  costive. 

*  I  suppose  it  is  natural,  as  one  advances  in  years,  to  adopt  milder  and  milder 
methods  of  treating  rheumatic  fever.  Sydenham  did  so.  In  1675,  the  date  of 
the  third  edition  of  the  "Observationes  Medicifi,"  he  was  trying  the  "  curatio 
repetitis  venaj-sectionibus:"  in  1680,  he  writes  to  the  Warden  of  Caiua  College, 
Cambridge,  "  verosimile  esse  judicabam  morbum  diasta  simplici,  admodum  refri- 
gerante,  et  mediocriter  nutriente,  tegro  imperata,  aeque  feliciter  ac  repetitis  venae- 
sectionibus  profiigari  posse;  etiani  evitatis,  quie  alteri  methodo  adjungebantur, 
incommodis:  neque  me  fefellit  dittta  e  scro  lactis  phlebotomi;o  loco  substituta." 
This  is  repeated  in  the  revised  edition  of  the  "  EpistolsB  Responsoria?,"  date  1685. 


RHEUMATIC  FEVER.  165 

No  selection  of  cases  was  made,  but  each  method  was  adopted 
in  every  case  for  a  time. 


1.  Mesults  of  drugs  on  the  diu'cition  of  illness. 

Of  the  26  treated  Avith  niter  the  mean  stay  in  hospital  was 
40-0  days. 

Of  the  141  treated  with  the  !i)j  bihoral  doses  of  bicarbonate 
of  potash,  the  mean  stay  in  hospital  was  34-3  da3's. 

Of  the  33  treated  with  less  quantities  of  the  potash,  the  mean 
stay  in  hospital  was  40*0  days. 

Of  the  25  treated  without  curative  drugs  the  mean  stay  in 
hospital  was  27*7  days. 

If  we  exclude  the  last  class,  which  is  as  yet  imperfect  for  sta- 
tistical purposes,  as  it  does  not  include  examples  of  all  the  four 
seasons,  it  would  seem  that,  though  smaller  doses  exert  no  effect, 
yet  that  full  doses  of  the  bicarbonate  of  potash  have  some  influ- 
ence in  shortening  the  duration  of  the  illness  from  the  time  of 
commencing  the  treatment  to  that  of  the  patients  being  suflB- 
ciently  convalescent  to  return  to  their  usual  occupations  with 
safety. 

I  may  remark  here,  that  any  other  measure  of  the  duration 
of  the  disease  is  untrustworthy  for  the  purpose  of  accurate  statis- 
tics. Suppose  you  say  you  will  measure  its  length  by  the  con- 
tinuation of  pain  or  by  the  presence  of  the  visible  external  phe- 
nomena of  tumefaction,  &c.,  you  will  find  yourself  baulked  in 
actual  practice.  The  different  degrees  of  susceptibility  to  pain 
exhibited  by  different  patients,  tbe  desire  of  some  to  extenuate, 
of  others  to  exaggerate  their  sufterings,  makes  it  impossible  to 
register  truly  even  the  exact  day  when  the  pain  ceases.  Whereas, 
in  such  a  short  period  as  it  lasts  after  the  commencement  of 
treatment  (namely,  two  or  three  days  usually),  the  exact  hour 
would  require  to  be  noted.  It  is  equally  impossible  to  measure 
when,  or  even  whether,  the  swelling  or  redness  is  all  gone;  for 
what  to  one  student's  eye  is  morbid  color,  to  another's  is  the 
normal  hue,  and  a  limb  which  to  the  patient's  sensation  is  swelled, 


IGG  RHEUMATIC  FEVEll. 

judging  by  the  Aveight  it  feels,  is  often  seen  to  be  of  its  natural 
size.  Those  who  have  set  clinical  clerks  to  observe  these  facts 
know  how  little  the  best  case-books  are  to  be  relied  on. 


2.  Effects  of  medicines  on  the  consequences  of  the  illness. 

In  respect  of  their  several  preservative  powers  against  the 
consequences  of  rheumatic  fever — 

Of  the  26  treated  with  niter,  there  Avere  attacked  with  acute 
inflammation  of  the  heart  while  under  treatment  (carefully  ex- 
cluding all  those  admitted  with  it  already  existing  as  a  result  of 
the  current  attack)  5,  or  19-2  per  cent.  (4  cases  of  pericarditis, 
1  endocarditis  only);  4  have  died — 2  of  inflammation  of  the 
heart,  and  2  of  sloughino;  back. 

Of  the  174  treated  with  bicarbonate  of  potash,  there  were  at- 
tacked with  inflammation  of  the  heart,  9,  or  only  5'3  per  cent.; 
none  have  died. 

It  would  seem  from  this,  at  first  sight,  as  if  bicarbonate  of 
potash  had  some  preservative  force.  But  the  fact  is,  that  nearly 
all  of  those  treated  by  the  alkaline  method  have  been  subjected 
also  to  what  both  rational  physiology  and  the  statistics  following 
seem  to  show  has  a  much  more  powerful  influence  than  any  other 
remedy  in  keeping  the  heart  free  from  inflammation.  I  refer  to 
blanketing  the  patients.* 


3.  Effects  of  blanketing. 

Up  to  May,  1855,  no  diff'erence  Avas  made  in  the  bedding  of 
my  patients  Avith  rheumatic  fever  from  that  of  others  in  the 
ward;  but  after  that  date  they  Avere  ordered  to  be  rolled  up  in 
blankets,  and  no  linen  Avas  let  touch  the  skin.  In  nearly  every 
case  the  orders  were  strictly  obeyed. 

Of  C3,  either  bedded  in  sheets,  or  who  had  willfully/  tliroivn  off 
their  blankets,  6  contracted  newly  pericarditis  at  least,  if  not 

*  See  this  process  described  in  a  formei'  lecture,  pages  145,  146. 


RHEUMATIC  FEVER.  167 

endocarditis  as  well ;  3  had  relapses  of  pericarditis  on  old  cardiac 
lesions;  1  had  endocarditis  alone;  on  the  whole  10,  or  nearly  16 
per  cent.,  had  inflammation  of  the  heart,  and  4  died. 

Of  184  in  blankets,  none  have  contracted  newly  pericarditis; 
none  have  died;  1  had  a  relapse  of  pericarditis  on  old  cardiac 
lesions;  5  had  endocarditis  alone;  1  a  relapse  of  endocarditis  on 
old  cardiac  lesion. 

One  of  these  included  cases  of  pericarditis  was  brought  on 
during  convalescence  by  the  patient  being  dowsed  with  cold 
water  for  an  accidental  hysteric  fit. 

Not  4  per  cent,  have  had  any  acute  aifection  of  the  heart; 
when  it  came  it  was  of  a  milder  character,  and  was  generally  to 
be  accounted  for  by  some  imprudent  exposure. 

That  is  to  say,  that  bedding  in  blankets  reduces  from  16  to  4, 
or  by  a  good  three  quarters,  the  risk  of  injiammation  of  the  heart 
run  by  patients  in  rheumatic  fever,  diminishes  the  interisity  of 
the  inflammation  when  it  does  occur,  and  diminishes  still  further 
the  danger  of  death  by  that  or  any  other  lesion;  and  at  the  same 
time  it  does  not  protract  the  convalescence. 


LECTURE    XIV. 

GONORRHCEAL    RHEUMATISM. 

Case. — Name  of  disease  not  stricthj  correct — Its  relation  to 
Pl/icmia — Mai/  occur  at  any  period  of  the  gonorrhoea — Not  a 
metastasis — Objection  to  any  treatment  grounded  on  its  being 
a  metastasis — Urethritis  a  worse  disease  than  gonorrhoea — 
Possible  peculiarity  of  gonorrhoeal  virus  in  these  cases — Rarity 
of  such  severe  cases  as  this  shown  by  the  7'esults  of  seventeen 
other  cases,  which  represent  the  more  usual  aspects  of  the  dis- 
ease— Specimen  of  a  more  usual  case  of  gonorrhoeal  rheuma- 
tism, and  its  treatment — Recurrence  of  gonorrhoeal  rheumatism. 

[Clinical,  St.  Marijs,  May  30,  1863.) 

Mrs.  "W — ,  aged  twenty-six,  exhibited  on  February  12,  symp- 
toms resembling  to  my  eyes  those  of  a  first  attack  of  acute 
synovial  rheumatism.  She  had  been  seized  three  days  before 
with  pains  in  the  joints,  and  the  right  knee  and  left  elbow  were 
much  swollen,  and  showed  a  slight  erythematous  blush  of  red- 
ness. There  was  headache  and  thirst;  the  pulse  was  112,  and 
the  tongue  white  and  furry.  The  case  so  strongly  resembled 
one  of  rheumatic  fever,  and  so  little  one  of  gonorrhoeal  rheuma- 
tism, and  moreover  the  latter  is  so  rare  in  the  female  sex,  that 
I  felt  no  hesitation  about  the  diagnosis,  and  put  her  on  the  alka- 
line treatment  for  the  disease  I  thought  it  was,  with  the  addition 
of  a  few  leeches  to  the  affected  joints.  This  went  on  till  the 
third  week  in  March,  when  the  extreme  obstinacy  of  the  painful 
swelling,  and  its  fixture  in  particular  joints,  induced  me  to  make 
a  more  particular  examination  of  the  case  with  a  view  to  a  revi- 
sion of  my  diagnosis.  She  then  confessed  the  following  sad 
tale : — Three  years  previously  she  had  been  infected  by  her  bus- 


GONORRHCEAL  RflEUMATISM.  169 

band  with  syphilis,  and  bore  a  diseased  dead  chihi.  Again  she 
became  pregnant,  having  in  the  meantime  had  secondary  sore 
throat  and  a  cutaneous  eruption.  The  second  cliihl  was  born  at 
seven  months,  and  lived  but  a  few  hours.  It  also,  had  an  erup- 
tion on  its  body.  She  said  she  was  again  pregnant  with  a  third, 
and  was  anxiously  fearing  for  its  life  too,  as  she  had  then  a 
purulent  discharge  contracted  from  her  worthless  husband. 
Curiously  enough,  he  was  stated  by  her  to  be  also  suffering  from 
what  she  called  "rheumatic  gout,"  that  is  to  say,  a  disorganiz- 
ing inflammation  of  the  joints,  Avhich  had  followed  his  gonor- 
rhoea,* It  was  satisfactory  to  hear  of  the  punishment  of  the 
guilty  as  well  as  of  the  innocent. 

I  then  changed  the  treatment,  leeched  freely,  and  blistered 
the  principal  joints,  applied  constant  poultices,  and  gave  her 
iodide  of  potassium  to  the  amount  of  thirty  grains  a  day.  In 
the  chronic  state  which  the  complaint  had  assumed,  the  blisters 
(according  to  the  patient's  statement),  gave  more  relief  to  the 
pain  than  leeches,  and  the  result  of  this  treatment  was  to  reduce 
the  size  of  the  joints  b}^  the  absorption  of  synovia,  and  to  relieve 
the  patient  much.  But  I  am  sorry  to  say  the  right  knee  and 
left  elbow  appear  to  me  too  much  disorganized  for  any  likelihood 
of  her  ever  entirely  recovering  the  free  use  of  them. 

On  May  26,  she  was  confined  of  a  healthy  child  at  the  full 
term,  so  that  it  must  have  been  begot  at  the  end  of  September 
last  year.  At  that  time  she  is  sure  that  her  husband  had  no 
complaint  of  any  kind,  and  that  he  did  not  have  the  gonorrhoeal 
discharge  I  have  spoken  of  till  the  middle  of  December.  This 
accounts  for  the  germ  of  the  infant  being  healthy;  and  it  is  an 
encouraging  circumstance  to  find  the  filtration  (if  I  may  so 
speak)  of  the  mother's  blood  through  the  placenta  purified  it  of 
the  poison  which  began  to  work  in  her  system  afterwards,  when 
her  baby's  ante-natal  life  was  advanced  to  about  four  and  a  half 
months.  It  is  valuable  also  to  know  that  the  thirty  grains  of 
iodide  of  potassium,  which  she  took  daily  for  ten  weeks,  and  left 

*  I  afterwards  found  this  man  in  Middlesex  Hospital,  under  the  care  of  Dr. 
Stewart.  This  case  was  entered  in  the  case-book  as  one  of  gonorrhoeal  rheuma- 
tism, and  it  seems  he  had  had  several  previous  attacks  of  the  same  nature. 


170  GONORRIICEAL  RHEUMATISM. 

off  only  when  in  labor,  has  no  bad  effect  on  utcro-gestation  and 
may  be  safely  given  to  breeding  women. 

You  have  seen  her  to-day  fulfilling  the  maternal  duty  of  suck- 
ling her  healthy  infant. 

During  the  last  fortnight  of  pregnancy  there  was  a  singular 
firm  elastic  tumefaction  in  the  vastus  externus  of  the  right  thigh. 
It  felt  like  very  soft  India  rubber,  Avas  painless,  distinct,  and  as 
big  as  a  large  orange.  What  it  was  I  do  not  know,  and  it  has 
now  disappeared  almost  entirely.  I  do  not  think  it  had  any 
connection  with  those  remarkable  swellings  in  the  muscles  which 
we  find  in  syphilitic  patients,  because  these  do  not  vanish  so 
quickly,  being  much  more  permanent. 

Before  I  proceed  to  comment  upon  the  disease  which  has  been 
the  special  object  of  treatment  in  this  case,  I  would  remark  upon 
the  healthiness  of  her  present  child.  Such  cases  are  a  strong 
negative  reply  to  a  doctrine  which  is  very  popular  as  to  the  irre- 
movability of  the  syphilitic  virus.  I  mean  the  doctrine  which 
maintains  that  when  it  has  once  gained  a  firm  hold  of  the  con- 
stitution, it  is  always  transmitted  to  all  future  progeny.  Here 
you  have  convincing  evidence  of  the  constitutional  affection  in 
the  deaths  of  the  two  first  fruits  of  the  womb,  and  evidence  of 
its  eradication  in  the  health  of  the  third. 

Gonorrhoeal  rheumatism  is  a  convenient  conventional  term 
which  we  continue  to  employ  really  for  want  of  a  better.  It 
designates  a  certain  specific  acute  or  subacute  inflammation  of 
joints  and  the  neighboring  white  tissues,  bearing  in  its  external 
aspect  a  resemblance  to  sometimes  one  and  sometimes  another 
of  the  forms  of  the  disease  it  is  named  after.  But  it  has  not 
the  slightest  other  relation,  cither  pathological  or  therapeutical, 
besides  external  similarity,  to  rheumatism. 

It  is  really  due  to  a  poison  absorbed  into  the  blood  from  a 
mucous  membrane  affected  with  purulent  gonorrhoea,  and  thus 
has  more  claim  to  be  classed  by  the  side  of  pyoemia  than  in  the 
position  where  it  is  now  placed.  Like  pyaemia  too  it  has  a  strong 
tendency  to  disorganization  of  the  affected  part;  pus  and  fibrin 
are  formed,  and  the  tissues  are  destroyed  in  bad  cases.  Like 
py?emia  too  it  does  not  exhaust  itself  by  the  inflammations  which 


GONORRIKEAL  RHEUMATISM.  171 

arise;  it. is  not  an  acute  disease  in  the  sense  of  tendino-  to  re- 
covery,  but  a  chronic  disease  getting  worse  and  worse  if  not 
arrested.  It  is  an  accident  of  gonorrhoea,  not  an  essential  part 
of  it,  just  as  pj?emia  is  an  accident  of  surgical  operations  on 
wounds. 

Its  extreme  rarity  in  the  female  sex  is  an  additional  evidence 
in  favor  of  the  poison  being  absorbed  from  the  locally  diseased 
part.  In  woman  the  mucous  membrane  principally  affected  by 
gonorrhoea  is  the  vagina,  a  tough  strong  surface  which  bears  a 
great  deal  of  ill-treatment  without  serious  injury.  Its  diseases 
have  but  little  influence  on  the  general  health.  But  the  male 
urethra  is  a  much  more  delicate  part,  and  we  can  easily  com- 
prehend that  it  should  oftener  take  up  the  gonorrhoea!  virus  and 
communicate  it  to  the  rest  of  the  body. 

Being  an  accident  it  may  occur  at  any  period  of  the  gonor- 
rhoea, sometimes  happening  only  a  fcAV  days  after  the  first  com- 
mencement of  the  running;  but  by  the  simple  doctrine  of  chances 
of  course  more  likely  in  the  longer  period  before  the  patient  is 
free.  Hence  it  often  appears  just  as  the  urethra  or  vagina  is 
getting  well,  and  so  has  been  reckoned  an  instance  of  metastasis. 
Metastasis  however  it  is  not,  for  often  and  often  the  discharge 
continues  as  bad  as  ever,  or  even  grows  worse,  while  the  joints 
are  swollen.  And  when  the  joints  get  better,  there  is  no  return 
or  aggravation  of  the  original  ailment. 

This  is  not  merely  a  pathological  question ;  for  on  the  notion 
of  metastasis  it  has  been  proposed  to  try  and  bring  back  the 
gonorrhoea  to  the  genital  organs  by  irritating  injections.  I  have 
seen  this  actually  done,  but  without  any  of  the  desired  effect  on 
the  arthritic  aflFection.  Even  if  it  were  a  curative  operation  I 
should  be  averse  from  practising  it,  for  the  disease  which  you 
thus  give  the  patient  is  not  true  gonorrhoea,  but  urethritis  or 
vaginitis,  and  that  of  a  chronic  character — a  much  worse  thing. 
I  say  it  is  a  much  worse  thing,  because  it  is  so  dangerous,  so 
very  difficult  of  cure,  not  rarely  indeed  proving  quite  incurable. 
I  published  in  the  "Lancet  "  two  years  ago,*  the  case  of  a  young 

*  Viz.,  June  15,  1861,  in  a  clinical  lecture  given  tit  St.  Mary's  but  not  repub- 
lished in  this  volume,  as  it  has  no  special  bearing  on  the  Renewal  of  Life,  or 


172  GONORIllKEAL  RHEUMATISM. 

man  who  died  of  inflammation  of  the  bladder  caused  by  the  man- 
ipulations of  a  spermatonhoeist  on  his  urethra,  and  I  contrasted 
there  the  violence  of  the  disease  artificially  produced  with  the 
mildness  of  a  real  specific  gonorrhoea  virulenta  left  to  nature. 
A  clergyman  sometimes  consults  me  about  his  general  health 
who  has  had  purulent  urethritis  for  the  last  three  years,  for 
which  he  has  been  to  several  of  the  principal  surgeons  in  London, 
and  tried  all  sorts  of  local  remedies  without  relief;  so  that  he  has 
now  made  up  his  mind  to  bear  it  with  patience  and  try  no  more. 
It  was  first  caused  by  a  too  zealous  practitioner  having  passed  a 
catheter  to  ascertain  whether  certain  nervous  urethric  symptoms 
were  due  to  stricture.  It  was  at  one  time  suggested  that  the 
catheter  might  have  been  an  infected  one,  but  the  absence  of 
any  specific  virus  was  proved  by  my  patient's  wife  not  contract- 
ing gonorrhoea,  though  he  had  not  forgone  matrimonial  inter- 
course. It  is  a  simple  chronic  urethritis,  just  such  as  we  should 
cause  by  local  irritants,  and  I  think  with  cases  of  this  sort 
before  my  eyes  I  am  quiie  justified  in  deeming  urethritis  a 
worse  thing  than  gonorrhoea,  and  in  declining  to  use  it  as  a 
means  of  cure. 

To  return  to  the  patient  now  under  our  observation.  She 
will  tell  you  that  there  has  been  nothing  like  a  metastasis  to 
other  parts  of  her  body ;  the  purulent  discharge  continued  quite 
unaffected  by  the  swelling  of  the  joints,  and  she  says  the  same 
is  true  of  her  husband  also. 

It  is  a  very  singular  thing  that  the  gonorrhoea  in  both  husband 
and  wife  should  have  been  followed  by  the  articular  affection;  it 
looks  as  if  there  Avas  something  special  in  the  form  of  the  original 
disease.  But  in  point  of  fact  such  an  occurrence  is  quite  ex- 
ceptional, and  may  be  a  mere  coincidence.  Indeed,  my  only 
reason  for  mentioning  it,  is  to  warn  you  of  its  rarity,  in  order 
that  you  may  not  put  it  down  in  your  pathological  sketch  of 
gonorrhoeal  rheumatism. 

I  must  also  warn  you  of  the  rarity  of  such  severe  consequences 

indeed  on  therapeutics  at  all.  It  was  made  public  for  the  purpose  of  exposing 
tlic  practices  of  the  spermatorrhccists,  and  others  who  live  hy  working  on  the 
prurient  delusions  oF  the  ignorant. 


GONORRHCEAL  RHEUMATISM.  173 

of  gonorrhceal  rheumatism  as  these  which  you  see  before  you  now. 
In  the  great  majority  of  instances,  especially  if  they  are  treated 
early  and  actively,  complete  recovery  results.  I  have  not  had 
an  opportunity  of  bringing  such  a  case  before  my  present  class, 
because  there  has  not  been  one  under  my  care  lately;  so  I  will 
extract  a  few  examples  from  my  old  case-books. 

William  M.  (Number  in  Hospital  Register  of  in-patients, 
2801),  aged  twenty-two,  admitted  in-patient  November  26, 1853, 
had  pain  in  one  hip,  with  swelling  and  redness  of  the  feet  and 
ankles.  Pie  got  no  better  for  treatment  with  niter  and  warm 
baths  ;  and  then  it  was  found  that  he  had  a  gonorrhoeal  discharge, 
and  confessed  that  he  had  had  a  similar  sort  of  rheumatism  with 
gonorrhoea  three  years  previously.  He  was  cupped  several  times 
on  the  affected  joints,  and  got  well. 

Thomas  J.  (No.  4119),  aged  forty,  admitted  October  27, 
1854,  had  contracted  gonorrhoea  and  got  cold  in  a  hay-field  in 
August,  and  had  had  pains  and  swellings  of  the  joints  ever  since. 
He  had,  on  admission,  swellings  of  the  right  wrist  and  was  help- 
less from  pain  in  the  knees,  though  those  latter  joints  were  not 
apparently  enlarged.  He  got  better  in  six  days  with  warmth, 
niter,  and  colchicum,  and  was  dismissed. 

James  C.  (No.  4202),  aged  twenty-six,  was  admitted  Novem- 
ber 17,  1854.  Five  years  previously  this  man  had  contracted 
what  he  called  "venereal  disease,"  accompanied  by  a  urethral 
discharge.  Immediately  afterwards  his  knee  became  swollen 
and  painful,  and  had  remained  so  ever  since,  in  spite  of  blister- 
ing. On  admission,  the  right  knee  measured  in  circumference 
17  inches,  the  left  13J  inches.  The  right  elbow  was  also  en- 
larged and  stiff.  The  jaw-joint  had  been  similarly  affected,  and 
he  could  open  his  mouth  but  a  very  little  way.  The  orifice  of 
the  urethra  was  red,  and  itched  a  good  deal,  but  there  was  no 
gleet.  Colchicum  internally,  and  iodide  of  mercury  ointment 
to  the  joints  did  him  no  good.  He  was  then  treated  with  leeches, 
iodide  of  potassium,  and  copaiba.  The  pains  were  relieved,  and 
the  circumference  of  the  largest  joint  was  reduced  to  15|  inches 
by  the  second  week  in  March.  He  had  then  been  in  the  hos- 
12 


174  GONORRHCEAL  RHEUMATISM, 

pital  more  than  four  months,  and,  as  he  considered  himself  able 
to  work,  I  dismissed  him. 

David  0.  (No.  5117),  aged  thirty-eight,  was  admitted  July 
10, 1855.  After  infection  by  gonorrhoea  three  -weeks  previously,  t 
pain  and  swelling  of  the  left  knee,  and  pain  at  the  side  of  the 
head,  had  come  on.  There  was  a  good  deal  of  fluid  in  the 
synovial  sac,  and  he  thought  it  was  increasing.  The  urethral 
discharge  was  irregular,  sometimes  absent,  sometimes  present. 
He  was  ordered,  for  about  ten  days,  three  grains  of  calomel 
every  night,  and  a  senna  and  a  jalap  draught  in  the  morning, 
and  leeches  were  applied  to  the  knee  every  other  night  for  four 
times,  and  a  weak  chloride  of  zinc  injection  used.  The  dis- 
charge and  rheumatism  ceased  together,  and  he  went  out  well  in 
forty-five  days. 

James  K.  (No.  7717),  aged  twenty-four,  was  admitted  April 
17,  1857,  with  pain  and  swelling  of  several  joints,  accompanied 
by  redness  of  one  wrist.  He  was  treated  at  first  with  alkalies 
as  for  acute  rheumatism.  Then  sclerotitis  was  observed  in  one 
eye,  and,  on  examination,  he  was  found  to  have  a  purulent  dis- 
charge from  the  urethra,  which  he  had  hitherto  concealed.  He 
was  leeched  round  the  eye  and  joints,  and  both  got  well  at  the 
same  time  that  the  urethra  ceased  to  secrete  pus.  He  was  in 
the  hospital  thirty-three  days. 

William  B.  (No.  8290),  aged  twenty-one,  admitted  August 
21,  1857,  at  Whitsuntide  had  become  infected  with  gonorrhoea, 
which  had  continued  ever  since.  At  the  beginning  of  July  his 
ankles  and  one  wrist  got  painful  and  swollen.  They  were  not 
red  on  admission,  though  he  stated  that  they  had  been  so  pre- 
viously. For  the  first  day  he  was  treated  with  bicarbonate  of 
potash,  but,  on  the  history  being  made  out,  it  was  left  off".  The 
treatment  was  changed,  he  was  bled  once  and  leeched  twice, 
and  took  copaiba  with  some  relief.  Then  he  was  packed  for 
an  hour  a  day  in  a  wet  sheet,  but  experienced  no  advantage  at 
all  from  it.  Then  he  took  forty -five  grains  of  iodide  of  potas- 
sium in  decoction  of  bark  daily,  and  went  out  cured  on  the  30th 
of  October. 

Frederick  M.  (No.  in  Annual  Register  497),  aged  twenty-six. 


GONORRIICEAL  RHEUMATISM.  175 

a  butcher,  caught  gonorrhoea  in  the  beginning  of  July,  1858, 
and  was  an  out-patient  of  this  hospital  for  it,  not  having  any 
bad  symptom  to  require  his  admission.  The  discharge  ceased, 
apparently  in  consequence  of  treatment,  and  about  the  same  time, 
he  began  to  suffer  from  pain  in  the  knees  and  ankles.  They 
soon  swelled,  and,  on  his  admission  as  an  in-patient  on  August 
19  of  the  same  year,  were  slightly  red.  His  feet  and  ankles 
were  freely  leeched,  and  he  had  senna  every  morning.  As  the 
pains  relaxed,  iodide  of  potassium  was  also  given.  He  was  dis- 
charged as  cured  in  twenty-four  days,  but  he  was  admitted  again 
under  Dr.  Alderson  in  the  following  November,  and  received 
benefit  from  colchicum. 

Cornelius  W.  (No.  581),  aged  twenty-five,  was  admitted  Sep- 
tember 24, 1858,  with  pains  in  the  hands  and  feet,  moving  about 
in  those  affected  parts,  but  not  attacking  the  larger  joints.  The 
patient  presented  at  first  the  appearance  of  slight  subacute 
rheumatism,  but,  as  it  came  out  that  he  had  gonorrhoea,  he  was 
treated  with  iodide  of  potassium,  purgatives  every  morning  and 
hot  baths.  He  began  to  get  better  immediately,  and  left  the 
hospital  in  ten  days. 

William  M.  (No.  359),  aged  twenty-eight,  admitted  Midsum- 
mer-day, 1859,  stated  that  three  years  previously  he  had  suffered 
from  gonorrhoea,  which  had  been  accompanied  by  severe  pain 
and  swelling  of  the  knees.  At  the  beginning  of  the  current 
month  he  had  again  contracted  the  same  complaint,  and  the 
knees  a^nd  feet  swelled  and  became  painful.  On  admission  there 
was  still  a  running  from  the  urethra,  and  the  swollen  ankles  had 
a  slight  blush  of  redness.  He  was  treated  with  leeches,  purga- 
tives, and  iodide  of  potassium.  He  left  the  hospital  nearly  well 
in  a  fortnight. 

Mary  Ann  M.  (No.  81),  aged  twenty-nine,  w-as  admitted  Feb. 
10,  1860,  and  treated  as  a  case  of  subacute  rheumatism.  She 
went  out  disappointed  of  relief  on  the  16th  of  the  next  month. 
It  appeared  she  had,  a  few  weeks  previous  to  admission,  con- 
tracted gonorrhoea,  and  that  very  possibly  was  the  cause  of  the 
obstinacy  of  her  symptoms,  especially  as  she  was  not  treated 
accordingly.     I  extract  the  case  mainly  as  a  possible  example  of 


176  GONORRIICEAL  RHEUMATISM. 

gonorrlioeal  rheumatism  in  the  female,  not  leading  to  disorgan- 
ization of  the  joints,  as  has  happened  to  the  patient,  whose 
history  began  this  lecture. 

Henry  P.  (No.  91),  aged  twenty-  three,  was  admitted  Feb.  10, 
1860.  Eighteen  months  previously  a  purulent  urethral  discharge 
(which  had  continued  for  nearly  two  years)  ceased,  and  about 
the  same  time  he  began  to  be  affected  with  pains  in  the  knees 
and  feet,  which  got  so  tender  he  could  not  stand  upon  them. 
The  feet  were  thoroughly  well  leeched  three  times,  he  was  purged 
and  took  iodide  of  potassium,  and  in  three  weeks  was  well  enough 
to  return  to  his  work  as  a  painter. 

James  B.  (No.  758),  a  smith,  aged  twenty-eight,  had  contracted 
gonorrhoea  virulenta  two  years  previously,  but  the  purulent  dis- 
charge frequently  returned,  and  had  never  quite  ceased.  He 
had,  on  admission,  pain  and  a  collection  of  synovia  in  the  knee- 
joints,  for  which  he  had  been  from  time  to  time  under  treatment 
during  the  last  year  and  a  half  at  his  native  place,  Hastings,  but 
without  benefit.  He  was  admitted  into  St.  Mary's,  November  9, 
1860,  was  leeched  three  times,  and  had  iodide  of  potassium  so 
as  completely  to  restore  his  health,  at  all  events  for  the  time, 
and  left  well  December  3. 

Henry  L.  (No.  34),  a  gardener,  aged  thirty-nine,  was  under 
my  care  for  four  months  at  the  end  of  1859,  for  what  I  con- 
sidered and  treated  as  chronic  gout.  On  his  readmission  in 
January,  1861,  he  confessed  to  his  former  and  present  attack 
being  consequent  upon  "a  gleet."  What  he  complained  of 
principally  was  excessive  heat  and  tenderness  of  the  heels,  soles, 
and  toe-balls  of  both  feet.  They  got  red  and  swollen  when  he 
walked  upon  them,  and  quite  prevented  his  following  his  occu- 
pation. He  took  iodide  of  potassium,  was  bled  once,  and  was 
leeched  twice  on  the  feet.  In  about  a  fortnight  he  was  freed 
from  the  ailment  for  which  he  came  to  the  hospital,  but  unfor- 
tunately some  of  the  leech-bites  suppurated  and  sloughed,  and 
he  had  to  take  bark  and  remain  in  till  the  15th  of  March.  That, 
however,  was  not  so  long  as  he  had  been  under  treatment  in- 
appropriate to  his  disease  on  a  previous  occasion. 

William  B.  (No.  362),  aged  twenty-five,  was  admitted  May 


GONORRHCEAL  RHEUMATISM.  177 

18,  1861,  with  buboes  in  the  groin,  accompanied  by  a  purulent 
urethral  discharge  of  five  weeks'  duration.  His  knees  and 
ankles  had  become  swelled  and  painful,  for  which  he  came 
under  my  care.  He  was  at  first  treated  with  alkalies  for  sub- 
acute rheumatism,  and  was  reported  better ;  but  on  getting  up 
his  pains  immediately  returned  again,  and  he  was  put  upon  iodide 
of  potassium,  which  quickly  cured  him.  He  left  the  hospital 
June  14. 

Henry  P.  (No.  847),  aged  twenty-three,  was  admitted  August 
9,  1861.  Five  years  previously  he  had  had  gonorrhoea,  which 
got  well  without  any  bad  symptoms.  A  month  before  admission 
he  was  attacked  with  pains  in  the  ankles,  knees,  hips,  and  right 
elbow.  He  then  found  he  had  a  purulent  inflammation  of  the 
urethra,  with  a  scalding  on  making  Avater.  On  examination  the 
feet  and  knees  were  found  swollen,  and  there  were  some  super- 
ficial excoriations  on  the  glans  penis,  attributed  by  the  patient 
to  the  collection  of  discharge,  which  the  stiffness  of  his  joints 
prevented  him  from  cleaning  away.  (This  seems  to  show  the 
peculiar  acrimony  of  the  virus  in  these  cases,  for  ordinary  gon- 
orrhoeal  pus  does  not  excoriate  the  skin.)  This  patient  had 
also  gonorrhoeal  ophthalmia.  He  was  leeched  and  took  iodide  of 
potassium,  and  went  out  well  Sept.  6.  It  may  be  remarked  in 
passing,  that  his  leech-bites  also  inflamed,  like  Henry  L.'s,  but 
whether  that  is  the  fault  of  the  leeches  or  of  the  patients,  I  can- 
not say. 

John  B.  (No.  66),  admitted  January  24,  1862,  had  had  a 
chronic  purulent  discharge  from  the  urethra  for  a  year,  but  had 
experienced  no  further  inconvenience  from  it  till  January  20, 
when  he  was  taken  with  rigors  and  aching  in  all  his  limbs.  Then 
his  joints  swelled.  He  Avas  cupped,  leeched,  and  purged,  and 
had  blisters  applied  to  the  knees,  and  took  internally  copaiba  and 
cubebs.     He  went  out  well  on  the  21st  of  March. 

{Clinical,  St.  Marys,  November  14,  1863.) 

James  M.,  aged  forty-six,  a  butler,  caught  gonorrhoea  three 
months  ago ;  and  six  weeks  ago,  as  the  urethral  discharge  was 


178  GONORRIICEAL  IIIIEUMATISM. 

ceasing,  pains  commenced  in  the  elbows,  ankles,  and  knees. 
These  pains  were  fixed,  not  metastatic,  and  grew  worse  and 
worse  in  spite  of  treatment.  The  left  knee  swelled  more  and 
more,  and  at  his  admission  on  November  7,  there  was  a  con- 
siderable accumulation  of  synovia  in  the  joint.  His  general 
health  was  good,  his  appetite  large;  the  bowels,  pulse,  and  skin 
were  normal.  I  kept  him  in  bed,  starved  liim,  leeched  twice, 
and  steadily  fomented  the  enlarged  knee,  and  gave  him  a 
scruple  of  iodide  of  potassium  daily.  Under  this  treatment  for  a 
week,  the  swelling  has  quite,  and  the  pain  nearly,  disappeared 
from  the  knee ;  the  other  joints  feel  quite  well.  Yet  he  cannot 
straighten  the  leg,  the  tendons  of  the  ham  being  impeded  in 
their  action  by  having  contracted  partial  adhesions  to  the  sur- 
rounding parts.  I  fear  that  the  slight  pain  that  remains  will  be 
somewhat  obstinate,  and  that  we  shall  have  to  leech  the  knee  a 
good  many  times  before  it  disappears.*  If  the  contraction  re- 
mains after  that,  mechanical  means  to  free  the  tendons  may  be 
employed. 

I  detail  this  case  to  you  as  a  specimen  of  the  more  usual,  or 
mild  form  of  gonorrhoeal  rheumatism.  If  left  alone,  and  allowed 
to  be  ingrained  into  the  constitution  it  becomes  very  obstinate  of 
cure,  and  doubtless  would  have  done  so  in  this  instance,  unless 
the  patient  had  been  submitted  to  active  treatment  at  this  early 
stage.  Now  you  see  it  is  more  manageable,  but  still  by  no  means 
so  easy  of  cure  as  ordinary  rheumatism  or  gout. 

As  to  the  rationale  of  the  treatment.  The  reason  for  its 
adoption  is  experience  of  its  good  effects,  the  little  efiFect  which 
other  treatment  has,  and  the  certainty  that  the  tendency  of  the 
disease  is  to  get  worse  and  worse  if  left  alone.  My  conjectural 
explanation  of  its  action  is  as  follows  :  I  suspect  the  cause  of  the 
disease  to  be  a  virus  especially  fatal  to  the  vital  functions  of 
the  white  non-vascular  tissues,  Avhich  is  carried  to  them  from  the 
urethra  by  the  blood.     The  partial  loss  of  vitality  in  these  white 

*  He  was  leeched  eleven  times  before  he  left  the  hospital  for  Christmas  day, 
having  found  that  nothing  did  so  much  good  as  that  treatment.  His  leg  was 
not  ciuite  straight  even  then,  and  I  cannot  say  that  the  last  four  leechings  were 
of  any  use. 


GONORRHCEAL  RHEUMATISM.  179 

tissues  causes  congestion  and  inflammation  in  the  neighboring 
capillaries*  with  pains  and  extra  vascular  accumulation  of  serum. 
The  leeching  and  fomentations  act  upon  the  inflammation,  and 
the  iodide  of  potassium  directly  as  a  restorative  to  the  white  tis- 
sues ;  as  to  the  starving,  I  do  not  know  what  to  say — perhaps  it 
does  good  by  promoting  absorption — perhaps  it  is  not  so  requi- 
site as  we  suppose. 


(^Clinical,  St.  Marys,  February  6,  1864.) 

The  sequence  of  rheumatism  after  gonorrhoea  seems  to  depend 
more  upon  the  diathesis  of  the  individual  attacked  than  upon 
any  peculiarity  of  the  infecting  virus :  for,  while  some  have  the 
urethral  part  of  the  affection  over  and  over  again  and  suffer  no 
further,  there  are  others  who  never  contract  the  slightest  puru- 
lent discharge  without  the  limbs  being  afterwards  crippled.  This 
is  illustrated  by  a  man  who  was  re-admitted  on  the  2nd  instant, 
Henry  P.,  aged  27.  He  was  under  my  care  here  in  1860  for 
gonorrhoeal  rheumatism,  and  went  out  in  three  weeks  quite  cured 
by  leeches,  poultices,  rest,  and  iodide  of  potassium. f  He  seems 
to  think  himself  exceptionally  virtuous  and  lucky  in  having  not 
again  caught  gonorrhoea  till  last  August,  and  unlucky  in  its 
being  followed  in  five  weeks  by  painful  swellings  in  his  two 
ankles  and  one  knee,  which  have  continued  to  get  worse.  You 
heard  me,  in  rebuking  him  from  his  nauseous  vice  of  fornication, 
threaten  him  that  each  time  he  contracted  gonorrhoea  it  would 
certainly  be  followed  by  this  painful  consequence ;  and  I  believe 
that  I  was  not  at  all  exaggerating,  when  I  stated  that  possibly 
it  might  in  the  end  cripple  him  for  life,  for  I  have  seen  instances 
of  its  really  doing  so.  I  shall  this  time  put  him  under  the 
same  treatment  as  before,  with  probably  the  same  result ;  but 
I  felt  strongly  disposed  to  reject  him  as  a  patient,  for  having  a 

*  See  ''  Lister  oa  the  early  stages  of  Inflammation."     Pliilosopliical  Transac- 
tion of  Royal  Society,  Part  II  for  1858. 

■j-  The  case  is  catalogued  in  page  157  (No.  in  Reg.  91). 


180  GONORRHCEAL  RHEUMATISM. 

second  attack  after  he  had  once  received  such  a  -warning  of  the 
consequences  of  vice.  I  think  the  threat  of  rejecting  him  will 
have  an  influence,  for  though  he  has  been  under  medical  treat- 
ment four  months,  he  has  got  no  better,  and  feels  the  need  of  the 
leeching,  poulticing,  starving,  and  vigorous  nursing  which  he  will 
now  receive. 


LECTURE   XV. 

PERICARDITIS. 

Case  of  pericarditis  coming  on  in  the  hospital — Rarity  of  this 
circumstance — Explanation  of  its  occurrence  in  this  instance 
— Diagnosis  of  old  and  recent  disease  hy  the  physical  sigyis 
— Practical  value  of  diagnosis — Treatment  hy  leeches,  blis- 
ters, and  poultices — Prevention  better  than  cure — Case  illus- 
trative of  the  use  of  mercury  in  similar  circumstances,  and  the 
reason  ivhy  it  is  no  longer  employed  by  the  author — Fatal  case 
of  2^eriearditis  from  exposure  to  the  cold  dwnng  convalescence 
from  typh-fever  —  Two  cases  of  pericarditis,  one  arising 
from  a  linen  shirt  fro7it  next  the  skin  during  rheumatic  fever, 
the  other  of  doubtful  origin — Action  of  opium  on  the  pidse, 
and  variations  from  other  causes — Remarks  on  the  pain  of 
pericarditis — Case  illustrating  its  absence,  and  the  non-reduc- 
tion of  the  pulse  by  opiuin — Fatal  pericarditis  in  a  patient  of 
choreic  diathesis. 

{Clinical,  St.  3Iarys,  June  21,  1862.) 

There  has  been  lately  an  unfortunate  opportunity  of  observing 
pericarditis  come  on  in  the  hospital.  A  puny  girl,  named  Fanny 
R — ,  was  admitted  May  31.  Having  always  been  delicate, 
she  looks  younger  than  seventeen,  which  is  entered  as  her  age. 
She  never  to  her  knowledge  spat  blood,  but  often  has  had  cough, 
and  for  the  last  three  months  in  1860  was  in  the  Consumption 
Hospital.  Also  eight  years  ago  she  went  through  rheumatic 
fever.  On  entry  she  said  she  had  been  then  ill  four  days,  and 
that  she  had  been  attacked  with  rigors  and  with  pains  and 
swellings  in  the  knees  and  wrists  at  first.  However  nothing  of 
the  sort  was  to  be  found  on  examination  ;  but  dullness  on  percus- 
sion, joined  to  oegopbony  and  absence  of  breath  sounds,  showed 


182  PERICARDITIS. 

the  presence  of  pleuritic  fluid,  though  there  was  but  bare  evi- 
dence of  any  acute  inflammation  of  the  serous  membrane  in  the 
presence  of  stitch  on  inspiration.  In  spite  of  her  being  an  in- 
telligent girl,  she  seems  peculiarly  insensitive  to  pain  ;  so  that 
the  absence  of  pain  is  a  less  important  negative  sign  than  usual. 
She  was  treated  with  a  poultice  first,  and  then  a  blister  on  the 
side,  and  diet  of  beef-tea  and  milk.  It  was  on  the  night  of  the 
4th  that  the  blister  was  put  on.  She  was  going  on  very  well, 
improving  in  strength  and  in  power  of  inspiration,  till  the  morn- 
ing of  the  7th  instant,  when  she  complained  of  pains  in  the  hands 
and  wrists,  which  on  inquiry  were  found  swollen,  as  if  from  rheu- 
matic inflammation. 

She  strongly  denied  having  any  pain  in  the  cardiac  region, 
even  on  firm  pressure ;  so  that,  had  I  not  been  aware  of  her  de- 
gree of  insensibility  to  pain,  I  should  have  concluded  at  once  that 
the  heart  was  free  from  lesion.  Fortunately  I  was  cautious,  and 
on  listening  with  the  stethoscope,  a  loud  murmur  was  heard  with 
the  first  sound  of  the  heart,  loudest  indeed  at  the  center  of  the  < 
organ,  but  propagated  over  the  upper  part  of  the  chest.  Take 
warning  from  this,  and  do  not  omit  to  observe  whether  the  patient 
before  you  feels  like  other  people  or  not  before  you  let  your  diag- 
nosis be  guided  by  the  feelings  expressed. 

AVith  regard  to  this  murmur,  there  arose  a  question  of  diag- 
nosis, very  important  as  regards  treatment.  Did  it  denote  an 
old  incurable  injury  derived  from  the  former  attack  of  rheuma- 
tism, or  was  it  an  acute  state  admitting  of  restoration  ?  In  the 
first  place  there  was  in  favor  of  its  being  an  old  valvular  mur- 
mur the  fact  of  the  previous  rheumatism,  and  the  peculiar  liability 
of  children,  even  more  than  adults,  to  have  the  heart  aff'ected  : 
then  there  was  its  single  character  (pericardial  murmurs  being 
usually  double)  and  the  entire  absence  of  pain.  To  weigh  against 
the  latter  argument  might  be  urged  the  already-named  stoical 
character  of  the  patient;  and  in  favor  of  the  recent  nature  of 
the  injury  there  was  stated  the  fact  that  nobody  had  heard  it  be- 
fore, though  the  chest  had  been  examined  in  reference  to  the 
lungs.  But  on  the  other  hand  it  should  be  remembered  how  very 
apt  the  ear  is  to  let  pass  unheard  even  a  loud  sound  when  the 


PERICARDITIS.  183 

attention  is  directed  elsewhere.  So  you  see  there  was  an  awk- 
wardly even  balance  of  arguments. 

In  this  dilemma  I  found  the  advantage  of  what  I  can  recom- 
mend to  you  as  by  far  the  best  extant  means  of  distinguishing 
single  pericardial  and  valvular  murmurs — sounds  precisely  the 
same  in  their  effect  on  the  ear,  and  occurring  often  at  the  same 
period  of  the  cardiac  movements,  and  therefore  undistinguish- 
able  unless  particular  manipulation  be  used.  The  plan  is — first 
fit  the  stethoscope  firmly  and  steadily  on  the  place  where  the 
murmur  is  loudest,  and  get  impressed  on  the  auditory  nerve 
clearly  the  special  character  of  the  murmur — then,  keeping  the 
instrument  still  closely  applied  to  the  chest  in  the  same  position, 
remove  your  head  vei-y  gradually,  and  try  to  gain  a  point  at 
which  you  can  hear  the  normal  heart  sounds  without  the  mur- 
mur. If  you  can  do  this,  the  murmur  is  pericardial.  If  you 
cannot,  but  the  murmur  is  heard  as  far  off  as  the  heart  sounds, 
it  is  endocardial.  In  all  cases  where  the  disease  is  endocardial 
only,  or  pericardial  only,  the  knowledge  thus  obtained  may  be 
safely  acted  upon. 

I.  acted  upon  it  in  this  instance,  in  spite  of  a  prepossession 
derived  from  the  history  and  from  the  absence  of  pain,  that  it 
was  an  old  valvular  injury  which  gave  rise  to  the  symptom.  In 
three  days'  time  the  conclusion  was  proved  correct  by  the  mur- 
mur becoming  a  double  rubbing  with  the  familiar  characters  of 
pericarditis. 

I  had  enough  faith  in  the  test  to  order  directly  four  leeches 
to  be  applied  over  the  cardiac  region,  followed  by  a  half-jacket 
poultice,  and  to  attend  to  the  more  important  serous  membrane 
now  inflamed  instead  of  attending  to  the  pleura.  The  patient 
was  also  put  upon  the  usual  treatment  for  rheumatic  fever  which 
I  have  detailed  in  previous  lectures.  After  four  days  the 
double  rubbing  got  shorter  in  duration  and  more  limited  in  the 
extent  over  which  it  was  heard,  and  then  I  ordered  a  small  blister 
over  the  base  of  the  heart.  The  rheumatic  swelling  had  left  the 
hands,  so  the  alkaline  treatment  was  then  left  ofi",  but  the  poultice 
was  continued. 

I  have  related  these  details  to  impress  upon  you  the  plan  to 


184  PERICAllDITIS. 

be  pursued  in  rheumatic  pericarditis  from  whatever  cause  it  has 
been  unhappily  induced.  Had  the  painful  swelling  of  the  hands 
in  this  poor  broken-down  child  preceded  by  a  suiEcient  interval 
the  inflammation  of  the  heart,  we  should  have  had  a  timely 
warning,  and  possibly  the  usual  careful  treatment  pursued  by 
our  nurses  would  have  prevented  the  misfortune.  But  the  oc- 
currence of  both  at  once,  and  the  unlucky  neighborhood  of  the 
already  diseased  lung,  combined  to  inflict  upon  us  the  sad  sight 
of  an  irremedial  mischief  in  process  of  formation.  I  say  an  irreme- 
dial,  because  it  cannot  be  doubted  that  this  adherent  pericardium 
will  cause  her  to  suff"er  from  the  evils  of  diseased  heart  in  future 
years. 

One  part  of  the  treatment  which  needs  particular  remark  is 
the  application  of  blisters.  At  the  beginning  of  acute  serous 
inflammation  they  unquestionably  do  much  harm.  They  increase 
its  heat  and  violence,  and  all  the  more  the  nearer  they  are  to 
the  part  aff'ected.  The  action  of  the  cantharides  is  to  cause  a 
fibrinous  serum  instead  of  a  plain  serum  to  be  throAvn  out,  which 
is  a  result  decidedly  not  to  be  wished,  decidedly  to  be  deprecated 
at  the  beginning  of  inflammation.  But  at  a  later  stage,  when 
pus  is  our  chief  dread  and  not  fibrin,  then  the  virtues  of  can- 
tharides come  to  our  aid.  At  this  conjuncture  apply  your  blister, 
and  apply  it  as  close  as  you  can  to  the  afi'ected  part;  the  healing 
process  which  follows  its  action  on  the  healthy  tissue  spreads  by 
continuity  to  the  diseased  tissue,  and  you  feel  yourself  power- 
fully aiding  the  forces  of  life. 

Retain  a  poultice  on  the  cardiac  region  during  the  whole  time 
that  pericarditis  lasts.  Nothing  is  of  more  importance  in  the 
treatment.  Neither  leeches  nor  blisters  need  stand  in  the  way 
of  its  application ;  it  has  an  importance  at  least  equal  to  either 
of  them  in  restorative  action,  and  is  suitable  for  all  stages  of  the 
disease. 

{Clinical,  St.  3Ian/s,  July  5,  1862.) 

Fanny  R.,  whose  case  I  lectured  about  a  fortnight  ago,  has 
got  into  a  state  to  justify  her  discharge  from  the  hospital  in  a 


PERICARDITIS.  185 

few  days.  The  pulmonary  regions  have  become  resonant  on 
percussion,  though  some  crackling  {rdle  de  retour)  accompanies 
the  air  returning  to  the  scarcely  restored  tissues  of  the  left  lower 
lobe.  Moreover,  the  opposite  sides  of  the  pericardium  may  be 
adherent  at  some  points,  and  the  adhesions  impede  the  contrac- 
tion of  the  heart,  I  much  fear;  for  there  is  a  soft  initial  murmur 
with  the  systole  heard  as  far  oif  as  the  first  sound  can  be  heard, 
caused  probably  by  the  valve  not  clenching  completely  and  so 
allowing  of  regurgitation. 

The  pericardium  can  hardly  help  becoming  adherent  after  its 
inflammation,  and  the  moral  I  would  draw  from  this  case  is  to 
think  the  prevention  of  the  injury,  when  threatened,  a  thousand- 
fold more  important  than  its  treatment,  when  established.  I 
told  you,  six  weeks  ago,  in  a  lecture  on  rheumatic  fever,  how 
this  prevention  is  to  be  aimed  at,  and  how  it  may  generally  be 
accomplished.* 

I  do  not  order  mercury  in  acute  pericarditis,  and  I  will  frankly 
tell  you  why,  since  it  is  right  that  I  should  make  my  practice 
useful  to  you  as  a  warning  as  well  as  an  encouragement.  Ten 
years  since  a  robust  and  excitable  girl  of  sixteen  had  rheumatic 
fever ;  from  her  constitution  I  feared  she  was  likely  to  have  her 
heart  afi'ected,  for  young  persons  of  a  nervous  temperament  are 
much  the  most  liable.  I  had  then  an  impression  that  mercury 
would  prevent  the  occurrence  of  inflammation  in  serous  sacs.  I 
put  her  under  the  influence  of  mercury — the  pericarditis  came 
on,  and  in  its  most  virulent  form — and  the  patient  died  in  the 
height  of  it.  This  result  made  a  deep  impression  on  my  memory ; 
her  fair  young  face  always  rises  before  me  when  the  idea  is  mooted 
of  preventing  pericarditis  with  mercury,  and  I  shrink  from  using 
it.  Of  course,  to  the  reason  a  single  case  does  not  prove  so  much 
as  statistics  of  many,  and  I  do  not  cite  this  as  sufficient  evidence 
to  your  minds  against  the  use  of  mercury.  But  it  gained  a 
powerful  hold  on  my  imagination,  and  if  practitioners  would  be 
honest  to  themselves,  they  would  often  confess  that  some  such 
feminine  evidence  as  that  above  quoted  governs  a  good  deal  of 
their  practice.  If  I  am  illogical  in  my  reason,  at  all  events  I 
will  be  manly  enough  to  confess  it. 

*  See  page  147. 


186  PERICARDITIS. 

{Clinical,  St.  3Ian/s,  February  20,  1863.) 

I  have  to  relate  to-day  a  sad  occurrence  which  has  happened 
since  our  last  meeting.  The  poor  girl,  Elizabeth  J,,  about  whom 
I  lectured  to  you  three  weeks  ago,*  and  whom  I  described  as 
then  recovering  from  a  short  attack  of  typh-fever  caught  in  the 
hospital  during  convalescence  from  acute  rheumatism,  has  since 
died.  She  went  on  very  well,  and  had  begun  to  eat  meat  and 
to  be  up  and  dressed  on  the  outside  of  her  bed,  when  she  was 
exposed  to  severe  cold  from  the  ward  windows  being  all  opened 
during  the  frosty  days  we  had  last  week.  This  brought  on  an 
attack  of  pericarditis  on  the  14th,  of  which  she  died  on  the  16th. 
I  show  you  here  the  pericardium  honeycombed  over  with  fresh 
lymph.  But  I  doubt  if  it  was  her  first  attack  of  pericarditis. 
On  admission  she  stated  that  she  had  been  previously  subject  to 
rheumatism,  and  durincj  the  attack  for  which  she  was  admitted 
there  was  one  day  pain  on  pressure  on  the  cardiac  region,  suffi- 
cient to  make  me  order  leeches  to  be  applied,  although  there 
was  no  murmur.  I  think  it  is  to  some  former  attack  probably 
that  the  firmer  of  the  adhesions  are  due. 

1  mention  this  case  mainly  to  warn  you  against  exposing  to 
the  assaults  of  cold  persons  of  rheumatic  diathesis.  All  this  in- 
judicious ventilation  which  caused  our  patient's  death  was  intended 
to  provide  for  the  safety  of  others.  Because  she  had  typh-fever 
she  was  placed  between  two  open  windows,  and  continued  to 
occupy  the  bed  after  all  risk  of  infection  had  passed  away.  It 
was  a  sad  misadventure,  but  you  must  not  attribute  her  death  to 
fever,  or  your  statistical  calculations  will  be  erroneous. 


[Olinieal,  St.  3Iarij  s,  January  9,  1864.) 

You  have  visited  with  me  to-day  two  examples  of  pericarditis, 
w^hich  are  worth  notice. 

George  D.  is  a  pale  spare  man  of  unhealthy  aspect,  by  trade 
a  carpenter,  aged  nineteen,  who  was  admitted  December  22  for 

*  See  page  131. 


PERICARDITIS.  187 

rheumatic  fever  of  nine  clays'  duration,  principally  affecting  the 
feet  and  knees.  There  was  no  bed  for  him  except  one  close 
under  a  window,  which,  unfortunately,  cannot  be  always  kept 
shut.  Nevertheless,  he  was  wrapped  up  in  close  blankets,  and 
I  dare  say  would  have  done  very  well,  but  for  an  important 
neglect  of  part  of  the  usual  treatment.  You  know  I  give  strict 
orders  that  rheumatic  fever  patients  are  not  to  have  any  linen 
touch  their  skin.  Well,  on  my  visit  to  this  man  on  the  morrow 
of  Christmas  day,  I  found  him  with  a  pericarditis,  of  which  I 
had  made  out  the  absence  on  his  admission  and  on  Christmas 
eve.  And  on  putting  aside  the  clothes  for  the  purpose  of  auscul- 
tation, I  found  that  the  only  covering  to  his  bosom  was  cold, 
hard,  damp  linen.  My  rebuke  to  the  ward-sister  was  met  by  the 
statement  that  she  thought  it  was  only  a  linen  shirt  that  I  ob- 
jected to,  and  that  the  patient  really  had  on  one  of  calico.  This 
I  found  to  be  true  enough,  but  yet  there  was  a  linen  front  to  it 
(for  ornamental  purposes),  and  the  front  unfortunately  covers 
just  the  most  important  part  of  the  body,  the  cardiac  region.  I 
am  sure  we  may  safely  attribute  the  occurrence  of  pericarditis 
to  this  chilly  decoration. 

To  avoid  in  future  such  an  evasion  of  the  standing  orders  for 
the  treatment  of  rheumatism,  I  shall  have  a  flannel  waistcoat 
put  next  the  skin  of  each  patient  so  affected. 

George  D.  has  had  his  chest  leeched  and  poulticed,  and  has 
taken  opium  freely,  according  to  my  usual  practice,  and  the 
pericarditis  has  run  through  the  course  it  usually  takes  when 
not  very  severe.  First  there  was  pain  and  a  murmur  only  occa- 
sionally double,  Avhose  frictional  character  was  made  evident  only 
by  collateral  evidence;  then  the  murmur  became  faint  and  there 
was  slightly  increased  dullness  on  percussion  of  the  cardiac  region, 
with  pain  still  remaining,  indicating  an  accumulation  of  fluid  in 
the  sac;  then  a  freedom  from  pain,  accompanied  by  a  double 
friction  sound,  indicating  the  absorption  of  the  fluid.  To-day, 
the  fifteenth  after  the  first  assault  of  the  pericarditis,  the  murmur 
is  single  and  scarcely  to  be  heard,  the  sounds  being  very  soft 
and  feeble. 

George  D.'s  strength  had  been  much  reduced  by  the  rheumatic 


188  PERICARDITIS. 

fever,  prolonged  as  it  was  by  tlie  pericarditis,  so  that  at  the  be- 
ginning of  this  week  I  found  a  slight  sore  from  a  superficial 
slough  of  the  skin  on  the  sacrum.  Accordingly  I  put  him  upon 
bark  and  ammonia,  and  augmented  his  diet  to  an  extent  unusual 
in  rheumatic  fever.  To-day  the  sore  is  nearly  healed,  but  the 
patient  is  so  weak  that  he  can  scarcely  turn  in  bed. 

The  other  case  is  that  of  Ann  B.,  a  fresh-colored,  cherry-lipped 
girl,  aged  nineteen.  When  I  came  to  admit  patients  yesterday, 
I  found  her  in  the  waiting-room,  throwing  herself  back  in  the 
chair,  breathless  and  gasping,  and  plucking  with  her  hands  at 
the  fore  part  of  her  dress  as  if  she  would  tear  it  open.  She  said 
she  was  choked  by  violent  pain  in  the  front  of  her  chest,  cried 
out  and  whimpered,  and  was  so  exaggerated  altogether  in  her 
manner,  that  I  felt  doubtful  if  it  would  not  turn  out  to  be  a  case 
of  hysteria.  Yet  her  aspect  was  not  that  of  an  hysterical  per- 
son, so  I  sent  her  to  bed;  and  being  then  able  to  examine  the 
thorax,  I  found  localized  in  the  cardiac  region  excessive  pain  on 
pressure,  and  a  distinct  double  friction  sound.  The  breathing 
was  very  hurried,  and  the  pulse  120,  small  and  weak. 

When  more  composed,  the  history  she  gave  was  this :  she  has 
never  had  rheumatic  fever  or  any  other  serious  illness;  but  for 
several  winters  past  has  had  pain,  of  no  great  consequence, 
across  the  front  of  her  chest.  For  the  last  three  weeks  she  has 
felt  unwell,  but  has  not  been  laid  up  from  Avork  till  the  6th  in- 
stant. Then  this  pain  commenced,  got  rapidly  worse  on  the 
Tth,  and  on  the  8th  (yesterday),  as  I  have  said,  she  came  here. 
She  can  assign  no  cause  for  her  illness,  nor  can  anything  be 
elicited  by  cross-examination  to  account  for  it. 

I  ordered  her  a  dozen  leeches  to  the  cardiac  region,  to  be  im- 
mediately followed  up  by  a  continuous  linseed  poultice,  a  grain 
and  a  half  of  opium  every  four  hours,  and  "simple"  diet. 

At  our  visit  to-day  you  saw  a  great  change  in  the  twenty-four 
hours.  The  patient  had  not  been  made  sleepy  by  the  opium,  but 
had  been  calmed  in  a  remarkable  degree.  A  numerical  reckon- 
ing of  the  amount  of  calm  was  afforded  by  the  pulse,  which  had 
sunk  from  120  to  5Q,  was  firmer  and  stronger.  This  effect  of 
opium  is  very  important  in  pericarditis,  when  quiet  for  the  busy 


PERICARDITIS.  189 

heart  is  so  desirable  and  so  difficult  to  procure.  It  is  singvdar 
what  a  large  quantity  may  be  taken  without  hypnotism,  or  even 
constipation,  in  all  serous  inflammations.  So  that  when  time  is 
of  value,  as  in  this  case,  you  should  begin  with  what  cannot  but 
be  called,  under  ordinary  circumstances,  imprudently  large  doses, 
or  you  will  not  have  mounted  up  to  the  efficient  quantity  early 
enough  to  be  of  use.  I  have  increased  the  quantity  now  to  a 
grain  and  a  half  every  three  hours. 

Pressure  on  the  cardiac  region  gives  less  pain  to-day,  and  the 
heart  being  quieter,  the  stethoscopic  evidence  of  the  disease  is~ 
easier  to  make  out.    The  to-and-fro  friction  sound  is  well  marked. 

The  patient  says  that  at  present  her  chiefest  pain  is  caused 
by  breathing  deep  and  by  swallowing.  The  first  she  can  of 
course  shun,  and  I  dare  say  will  do  so.  The  second  is  to  a  cer- 
tain extent  unavoidable,  but  we  will  do  our  best  to  relieve  her 
by  giving  only  liquid  food,  and  in  very  small  quantities  at  a  time. 

[Clinical,  St.  Mary' s,  January  23,  18(34.) 

Ann  B.,  about  whose  pericarditis  I  lectured  to  you  lately,  has 
interested  us  by  the  variations  in  lier  pulse.  It  continued  slow 
till  the  12th,  when  a  visitor  in  the  middle  of  the  day  appears  to 
have  engaged  her  in  conversation  too  long,  and  it  rose,  so  that 
by  night  it  was  120.  She  continued  to  take  the  opium  (gr.  iss 
every  tliird  hour),  and  on  the  loth  it  dropped  to  90,  on  the  14th 
to  8G,  and  on  the  15th  to  80,  on  the  16th  to  76,  on  the  20th  to 
72,  and  on  the  23d  (to-day)  it  has  risen  again  up  to  88.  This 
rise  may  be  partly  due  to  the  patient's  menstrual  period,  which 
has  just  commenced,  making  her  sensitive  and  excitable,  partly 
perhaps  to  a  slight  relapse  of  inflammatory  action  in  the  peri- 
cardium. 

The  pericardium  has,  on  the  whole,  progressed  favorably ;  the 
friction  sound  continued  double  till  the  13th,  when  it  was  found 
to  be  single  only.  It  got  less  loud,  and  on  the  20th  one  could 
hardly  say  there  was  a  friction  at  all,  though  with  the  first  sound 
of  the  heart  there  was  a  peculiar  harsh  tone.  However,  to-day 
I  can  distinctly  detect  a  friction  sound. 


190  PERICARDITIS. 

The  opium  has  agreed  with  her  well.  On  the  16th  it  was  in- 
creased to  two  grains  every  three  hours,  and  it  produced  no  ab- 
normal sleepiness  or  constipation  ;  nor  has  it  prevented  the  return 
of  her  appetite,  for  on  the  20tli  she  was  ordered  a  mutton  chop, 
on  her  own  statement  of  feeling  very  hungry.  To-day,  the  23d, 
I  have  increased  the  dose  of  opium  to  gr.  iij  every  three  hours 
during  the  catamenia. 

Of  course  we  have  been  watching  for  any  symptoms  of  rheu- 
matic fever,  and  on  the  iGth  I  thought  that  a  pain  she  felt  in 
one  foot  was  an  announcement  of  its  approach;  but  that  passed 
away  quickly  and  was  accompanied  by  no  redness  or  swelling. 

I  am  anxious  to  draw  your  attention  to  the  more  than  ordinary 
pain  which  this  young  woman  has  experienced  from  her  peri- 
carditis. At  first  it  was  excruciating,  and  even  on  the  20th, 
when  the  friction  murmur  had  ceased,  firm  pressure  of  the 
cardiac  region  made  her  wince.  I  especially  wish  you  to  notice 
it,  because  there  is  a  case  of  pericarditis  which  was  admitted 
nearly  at  the  same  time,  where  there  is  a  remarkable  absence  of 
this  symptom. 

John  C,  a  journeyman  butcher,  aged  twenty-four,  was  taken 
ill  with  rheumatic  fever  on  the  10th  instant.  I  saw  him  first  on 
the  13th,  when  he  complained  energetically  of  the  painfulness  of 
the  swollen  joints,  but  disclaimed  having  any  inconvenience  in 
the  chest;  nor  till  I  pressed  my  stethoscope  on  the  cardiac  region 
really  hard,  would  he  allow  that  it  hurt  him.  Notwithstanding 
which,  when  I  applied  the  ear  I  found  a  loud  double  friction 
sound.  The  sounds  grew  coarser,  but  shorter,  up  to  yesterday, 
the  22d,  when  I  could  no  longer  hear  them,  and  conjectured  that 
adhesion  had  taken  place. 

I  cannot  explain  why  there  is  pain  in  one  case  more  than  in 
another;  it  certainly  does  not  denote  severer  disease,  because  in 
all  other  respects  the  man  was  the  worst  of  the  two  patients. 
Perhaps  it  may  have  something  to  do  with  the  absence  of 
rheumatism,  the  pain  of  which  withdraws  the  attention  of  the 
sensation  to  the  joints,  or  wherever  the  swellings  and  redness 
may  be. 

Attacks  of  non-rheumatic  pericarditis  are  more  common  in 


PERICARDITIS.  191 

private  practice  than  in  hospitals.  They  usually  arise  from 
similar  causes  to  those  which  cause  pleurisy,  namely,  exposure 
of  the  part  to  sudden  chills  while  its  vitality  is  lowered  by  pre- 
vious exertion.  I  had  a  case  this  week  arising  from  walking  out 
into  the  night  air  after  exertion  at  a  dinner  party;  and  in  boys, 
football  and  boating  are  often  to  blame. 

Tlie  treatment  of  John  C.  was  the  same  as  that  of  Ann  B.  He 
was  twice  leeched,  and  his  chest  is  still  wrapped  in  a  linseed 
poultice.  On  the  loth  he  Avas  ordered  gr.  iss  of  opium  every 
four  hours ;  and  on  the  17th,  as  he  was  somewhat  delirious,  and 
the  pulse  was  120,  gr.  ij  every  three  hours.  The  delirium  then 
ceased,  but  the  pulse  kept  up.  On  the  20th,  gr.  iij  every  three 
hours.  On  the  22d  he  said  he  was  certainly  more  drowsy  than 
usual,  but  the  bowels  were  not  made  costive  by  the  opium.  The 
pulse  kept  up  to  120.  As  he  was  entirely  free  from  rheumatic 
pains,  I  ordered  the  quantity  of  the  drug  to  be  diminished  to  gr. 
ij  every  three  hours,  which  he  is  continuing  to  take. 

The  extreme  quickness  and  weakness  of  this  man's  pulse 
throughout  has  made  me  very  anxious  about  him.  The  opium 
has  seemed  not  to  diminish  it,  as  it  did  in  Ann  B.,  and  that  is 
the  reason  why  I  have  pronounced  him  the  worst  of  the  two. 

In  Jolm  C.  you  have  seen  pericarditis  in  its  most  familiar 
aspect,  that  is  to  say,  arising  in  the  course  of  rheumatic  fever,  as 
a  consequence  of  the  exposure  of  the  chest  to  cold,  or  the  attempt 
at  bodily  exertion.  In  Ann  B.  there  is  no  evidence  of  its  con- 
nection at  all  with  rheumatic  fever.  In  the  case  I  am  going 
next  to  relate  to  you,  there  was  no  rheumatic  fever  present  in- 
deed when  the  pericardial  inflammation  came  on,  but  there  was 
a  diathesis  somewhat  connected  with  the  rheumatic,  though  in 
what  way  it  is  difficult  to  define.* 

Alfred  M.,  a  delicate  and  thin  boy  of  ten,  was  admitted  De- 
cember 18,  ult.,  for  chorea.  He  had  had  the  same  two  years 
previously,  and  also  at  some  periods,  which  he  could  not  remem- 

*  This  question  is  enlarged  upon  in  the  concluding  part  of  Lecture  XXIX, 
"  Ou  Chorea."  -^ 


192  PERICARDITIS. 

ber  accurate]^,  redness  and  swelling  of  the  joints.  On  admis- 
sion, he  said  his  feet  were  painful,  but  I  could  see  nothing  like 
rheumatic  swelling.  There  was  a  loud  rumbling  continuous  mur- 
mur with  the  heart's  action,  which  was  violent  and  tumbling. 
This  I  attributed,  I  cannot  say  how  correctly,  to  lesions  pro- 
duced by  old  disease.  The  cardiac  symptoms  were  better  after 
the  lad  had  been  quiet  in  bed  a  few  days  and  had  had  a  few 
leeches  on.  He  was  then  treated  with  arsenic  for  the  chorea, 
and  got  better,  so  as  to  be  playing  about  the  ward  with  some 
other  boys  up  to  the  morning  of  the  20th  of  January.  On  that 
morning  he  told  the  nurse  he  had  a  seA^ere  pain  in  the  front  of 
his  chest,  so  she  bade  him  lie  in  bed,  and  sent  immediately  for 
the  resident  medical  officer.  He  found  on  examination  a  loud 
double  friction  sound  in  the  cardiac  region,  and  immediately 
leeched  and  poulticed  it ;  but  the  lad  got  rapidly  worse,  and  died 
in  the  evening  of  the  same  day. 

You  see  here  the  heart  and  pericardium.  The  visceral  por- 
tion of  the  serous  membrane  is  partially  covered  with  grains  of 
soft  lymph,  in  some  places  forming  a  reticulated  coating:  the 
parietal  portion  has  a  smaller  quantity  of  the  same  lymph  at- 
tached to  it.  Exposed  parts  of  the  serous  membrane  are  (and 
were  still  more  when  first  taken  out)  deeply  stained  with  a  pur- 
plish red  congestion.  The  sac  was  filled  with  five  or  six  ounces 
of  transparent  scrum.  And  in  the  adjoining  pleura  of  the  left 
side  there  was  a  larger  quantity  of  similar  fluid  ;  but  as  they 
flowed  together  in  opening  the  chest,  I  could  not  apportion  the 
property  of  the  respective  cavities.  The  opposite  surfaces  of  the 
pleura  were  joined  by  some  delicate  threads  of  very  soft  lymph. 
The  other  viscera  were  normal  in  aspect. 

The  heart  is  large,  Aveighing  with  the  pericardium  10|^  ounces. 
It  has  not  been  opened  in  the  usual  way,  because  I  was  anxious 
to  show  you  the  phenomena  of  pericarditis  it  its  early  period, 
the  reddening  of  the  membrane  in  the  first  stage  of  death, 
and  the  soft,  almost  creamy,  coagula  of  lymph  which  produce 
friction  sounds.  But  I  can  hardly  doubt  that  there  is  old 
valvular  lesion  ;  and  to  the  existence  of  old  lesions  I  attribute 
the  rapidity  with  which  4he  patient  sank  under  what  I  suppose 


PERICARDITIS.  193 

may  be  called  an  acute  pericarditis,  occurring  without  rheuma- 
tism to  a  rheumatic  individual,  and  in  a  predisposed  heart. 
The  external  motive  cause  I  can  only  conjecture  to  be  some 
secret  escapade  of  the  poor  child's,  which  exposed  him  to  cold 
and  unauthorized  exertion,  and  which  he  concealed  from  us  for 
fear  of  a  scolding. 

[A  few  days  afterwards  John  C.  was  able  to  get  up,  eat  meat,  aad  leave  off 
opium.  He  was  discharged  cured  on  February  G.  Ann  B.  had  the  quantity 
of  opium  gradually  diminished  to  gr.  j  night  and  morning,  which  to-day  (Febru- 
ary lo),  she  says  makes  her  sleepy,  so  it  is  omitted  altogether.  There  is  no  mur- 
mur audible  in  the  cardiac  region,  but  the  first  sound  is  very  long.  She  is  up 
and  dressed.] 


LECTURE    XYI. 

PLEURISY. 

First  case,  and  its  treatment — Cases  of  pure  pleurisi/  not  common 
in  hospital  practice — It  is  a  slight  disease,  but  capable  of  being 
made  7nuch  more  severe  by  bad  management — Remarks  on 
blisters  and  on  local  bloodletting — Their  final  intention  res- 
torative— Poultices  —  Continuous  warmth  as  a  renewer  of 
life — Second  case — Chro7iic  effect  of  acute  pleurisg — Treat- 
ment— Diuretics — Blisters —  Third  case — Pycemic  pleurisy,  its 
fatality. 

{Clinical,  St.  Mary's,  July  5,  1862.) 

I  AM  glad  to  have  an  opportunity  of  bringing  before  you  to- 
day a  disease  so  common  in  practice  as  to  be  one  of  serious  import 
for  you  to  study,  but  of  which  specimens  do  not  often  occur  in 
our  hospital  wards — pleurisy  uncomplicated  with  further  inflam- 
mation of  the  lung. 

Thomas  G.,  a  day  laborer,  aged  twenty-nine,  was  warded  June 
19,  with  anasarca  of  legs  and  belly  of  a  fortnight's  duration, 
which  he  attributed  to  exposure  to  tlie  weather.  Ilis  urine  was 
found  to  be  albuminous.  The  resident  medical  officer  gave  him 
a  hot-air  bath,  a  jalap  purge,  and  some  draughts  of  nitric  ether 
and  digitalis.  When  I  visited  him  on  the  morrow  he  complained 
of  a  sharp  pain  on  both  sides  of  the  waist,  which  he  said  had 
been  coming  on  for  two  days  and  was  getting  worse.  On  aus- 
cultation I  heard  pleuritic  friction  beneath  both  scapulae  and  in 
the  lateral  regions  ;  the  normal  respiratory  murmur  was  still  to 
be  made  out  in  spite  of  it;  but  there  was  a  leathery  creak,  last- 
ing through  the  whole  of  respiration  and  the  latter  part  of  expi- 
ration.    The  tongue  was  furred,  and  there  was  thirst. 


PLEURISY.  195 

He  was  ordered  to  be  cupped,  but  as  the  instruments  had  un- 
luckily gone  to  be  mended  and  would  not  be  returned  for  an  hour 
or  two,  a  dozen  leeches  were  applied  along  the  lower  edges  of  the 
ribs,  in  the  infrascapular  region.  Immediately  they  came  off  a 
large  poultice  was  placed  all  over  the  back  of  the  chest. 

The  next  day  (June  21)  the  pain  and  fever  Avere  quite  gone, 
the  friction  sound  was  heard  over  a  limited  space,  and  on  the 
22d  had  departed  altogether.  The  poultice  was  continued  one 
more  day,  as  the  patient  remained  in  hospital  to  be  treated  for 
albuminuria. 

Pure  fibrinous  inflammation  of  the  pleura,  pleurisy  without 
any  affection  of  the  pulmonary  tissue,  you  have  as  yet  probably 
not  often  had  a  chance  of  seeing.  But  you  know  from  your 
post-mortal  experience  in  our  mortuary  how  common  it  must  be. 
There  are  few  even  of  the  most  healthy  chests  in  which  you  do 
not  see  old  adhesions  of  the  pleuritic  surfaces,  the  relics  of  pleu- 
risy, sometimes  in  one  part,  sometimes  in  another,  sometimes 
partial,  sometimes  universal ;  they  are  so  common,  that  they 
were  supposed  to  be  the  normal  condition  of  the  parts  when 
anatomy  began  first  to  be  studied  after  the  restoration  of  learn- 
ing. What  is  the  reason,  then,  that  you  have  but  few  opportu- 
nities of  learning  how  to  treat  this  very  common  disease  while 
you  are  pupils?  Simply  because  it  is  scarcely  ever  so  severe  as 
to  bring  the  patient  into  our  hospital  wards,  and  is  fatal  only  by 
very  rare  exception  ;  so  that  your  only  chance  of  observing  it  is 
when  it  is  joined  to  some  more  alarming  disorder.  The  man  who 
is  the  occasion  of  these  remarks  would  never  have  been  admitted 
to  St.  Mary's  had  he  not  been  taken  dropsical  at  the  same  time 
as  he  caught  his  pleurisy. 

Nine  times  out  of  ten  pure  pleurisy  begins  and  ends  with  a 
catching  pain  in  the  side  on  inspiration,  and  a  slight  inflam- 
matory fever,  making  the  patient  coddle  at  home  and  take 
slops,  but  not  employ  a  doctor.  It  would  be,  perhaps,  better 
for  him  if  he  did,  for  possibly  his  may  be  the  hundredth  or 
exceptional  case,  and  his  illness  may  turn  out  a  more  serious 
affair.  Moreover,  in  every  case,  the  pain  in  the  side  and  the 
fever  may  be  shortened  by  good  management  and  lengthened  by 
bad. 


196  PLEURISY. 

For  example — blisters  at  the  outset  of  pleurisy  invariably 
protract  tlie  duration  of  the  inflammation  and  make  it  more 
severe.  The  property  of  cantharides  is  to  augment  that  very 
fibrinous  crasis  from  which  the  membrane  is  already  suffering. 
Exposure  to  cold  and  to  changes  of  temperature,  baths  and  the 
like,  make  it  worse,  as  do  strained  postures  of  the  body  and  ex- 
ercise. Opiates  cove  rup  the  evil  with  an  anaesthetic  mask,  and 
prevent  the  patient  knowing  how  he  really  is.  Mercury  is  an 
unnecessary  call  upon  the  whole  system  to  make  destructive 
sacrifices  for  the  sake  of  a  very  small  and  not  highly  important 
member.  Purgatives  do  no  good,  and  expose  the  patient  to  catch 
cold  at  the  water-closet. 

On  the  other  hand,  the  treatment  you  saw  applied  gives  de- 
cided and  immediate  relief,  and  wards  off  the  risk  arising  from 
the  continuance  of  the  disease. 

It  is  necessary  to  remark  that  the  whole  of  it  was  not  meant 
for  the  benefit  of  the  pleura ;  the  hot-air  baths,  the  diaphoretic 
draughts,  and  the  jalap  were  intended  to  rid  the  skin  of  anasarca, 
and  were  successful  in  so  doing  ;  while  the  treatment  to  which  I 
design  to  call  your  attention  as  that  specially  appropriate  to 
pleurisy  is  the  application  of  the  poultice  and  the  leeches — the 
poultice  always,  and  the  leeches  whenever  the  pain  is  decidedly 
"catching"  or  "stabbing"  on  inspiration. 

I  will  speak  of  the  last  first,  as  it  is  most  open  to  exception. 

The  object  of  leeching  and  all  local  bloodletting  is  to  relieve 
inflammatory  congestion,  which  is  not  only  an  evidence  of  lost 
vital  power  in  the  local  blood-vessels,  but  also  the  cause  of  fur- 
ther loss  by  leading  to  the  other  stages  of  the  inflammatory  state. 
The  blood-vessels,  from  want  of  elasticity,  are  unable  to  empty 
themselves  naturally,  so  you  roughly  step  in  and  empty  them 
artificially.  You  mnj  perchance  say,  that  is  all  very  well  in 
external  inflammation,  when  you  can  draw  off"  the  blood  which  is 
causing  the  '"'"rubor"  and  '•'"tumor"  visible  to  the  naked  eye; 
but  you  may  doubt  how  the  pleura,  especially  the  pulmonary 
pleura,  is  to  be  aff'ected  by  depleting  the  capillaries  of  the  skin. 
Your  recent  experience  in  the  dissecting-room  reminds  you  that 
it  is  a  very  long  way  round  before  you  can  find  any  vascular  con- 


PLEURISY.  197 

nection  between  the  parts ;  you  may  think  local  bloodletting  only 
beneficial  by  detracting  so  much  blood,  and  that  a  small  vene- 
section would  be  more  convenient  and  equally  effectual.  It  is 
not  at  all  essential  that  there  should  be  a  vascular  connection 
between  separate  parts  for  altered  states  and  conditions  of  life 
to  spread  from  one  to  another.  I  have  seen  in  the  dead  body  a 
round  circumscribed  spot  of  costal  pleura  affected  with  fibrinous 
inflammation,  and  this  had  spread,  not  laterally  to  the  neighbor- 
ing surface  of  serous  membrane,  not  to  that  tissue  intimately  one 
with  it  in  vascular  connection,  but  to  the  opposite  surface  on  the 
lung,  between  which  and  its  substance  lay  the  great  gulf  of  the 
pleural  cavity — the  great  gulf,  anatomically  speaking,  but  not 
physiologically,  as  proved  by  this  instance.  If  this  gulf  can  be 
spanned  by  disease,  the  negation,  the  deficiency  of  life,  shall  it 
not  be  yet  easier  stepped  across  by  the  remedy,  the  renewer  of 
life  ?  I  do  not  myself  feel  any  hesitation  in  believing  firmly 
what  experience  seems  to  teach,  that  in  inflammations  of  serous 
sacs,  depletion  applied  to  the  external  surface  has  a  power  pro- 
portionate, not  alone  to  the  quantity  of  blood  taken,  but  in  an 
equal  degree  to  the  locality  from  which  it  is  taken. 

I  have  called  the  local  drawing  of  blood  a  "renewer  of  life," 
and  I  think  it  is  but  fair  to  explain  in  what  sense  I  so  speak  of 
it.  The  taking  away  the  vital  fluid  is  taking  away  part  of  the 
body,  and  is  so  directly  a  destructive  agent.  But  then  blood 
thus  lost  from  an  inflamed  part  is  not  all  loss ;  a  great  deal  of  it 
is  black,  "melanosed,"  partially  dead  and  unfitted  for  the  pur- 
poses of  life,  and  only  a  minority  of  its  constituents  can  really 
be  called  living.  Then  again,  granting  that  loss  of  blood  is  a 
direct  loss  to  a  living  body,  still  the  indirect  gain  is  a  full  com- 
pensation in  cases  Avhere  it  is  rightly  applied.  The  blood-vessels 
resume  their  elasticity,  their  current  renews  its  force,  and  loss  of 
substance  is  a  regaining  of  function.  So  that  a  destructive  be- 
comes in  the  end  a  constructive  remedy. 

In  the  action  of  poultices  there  is  not  even  a  seeming  paradox 
to  stumble  at.  Continuous  steady  warmth  is  the  most  direct 
agent  in  our  hands  of  vital  development.  It  not  merely  fosters 
vital  growth,  but  makes  that  growth  take  a  higher  form  of  life. 


198  PLEURISY. 

Mr.  Iligginbottom  found  tliat  different  detachments  of  tadpoles 
kept  in  the  dark  and  treated  with  different  degrees  of  tempera- 
ture, threw  off  their  tails  and  branchise,  and  developed  their 
lungs  and  became  frogs,  with  a  quickness  exactly  proportioned 
to  the  warmth  they  were  subjected  to.*  Do  not  let  any  experi- 
ments on  life  escape  you  :  turn  to  a  practical  use  even  that  which 
seems  at  first  glance  most  remote  from  practical  use.  Warmth, 
especially  when  kept  steady  and  even  by  moisture  joined  with 
it,  has  the  same  effect  on  the  failino-  functions  of  tissues  in  the 
higher  animals  as  in  the  lower;  it  raises  and  restores  the  life  to 
its  normal  force  of  development.  If  the  milk  is  scanty  in  the 
breast  of  a  suckling  mother,  a  hot  poultice  or  gentle  friction  with 
oil  Avill  revive  its  flow :  If  the  liver  ceases  to  make  bile,  hot 
fomentations  will  act  as  a  cholagogue.  As  heat  renews  the 
vitality  of  the  sluggish  glands,  so  also  it  renews  the  injured  mem- 
brane, which  had  been  lowered  to  that  condition  we  call  con- 
gestion or  inflammation,  into  the  higher  life  of  warm-blooded 
circulation.  As  it  developed  the  tadpole  into  the  frog,  so  it  de- 
velops the  half-killed  diseased  part  into  full  life. 

You  must  take  care  not  to  follow  up  the  application  of  quick- 
ening warmth  by  the  depressing  influence  of  cold,  or  it  becomes 
doubly  depressing  by  contrast.  Zour  poultice  must  be  kept  on 
hot  and  hot  till  all  pain  is  gone,  and  the  breath  can  be  drawn 
quite  freely  and  easily.  And  it  will  do  no  harm  to  beguile  your 
patient  into  retaining  it  even  a  little  longer,  as  was  done  in  the 
case  which  is  now  my  text. 

Such  means  will  rarely  fail  to  cut  short  an  attack  of  pure 
pleurisy. 

But  you  will  say  there  are  cases  of  pleurisy  which  are  not 
cut  short,  and  notably  just  now  there  is  one  lying  a  few  beds 
beyond  the  last  patient,  the  history  of  which  I  will  extract  from 
the  note-book. 

John   C,  a  railway  navvy,  aged  thirty-four,  always  enjoyed 

*   20  tadpoles  placed  in  a  dark  cellar  at — 

56°  produced  in  89  days  10  frogs, 

53°  "  103    "       10     " 

51°  "  131     "         8     " 

—Proceedings  of  the  Royal  Society  (18G2).     Vol.  xi,  No.  48,  p.  532. 


PLEURISY.  199 

good  health  till  six  months  ago,  when,  on  the  third  day  after 
sleeping  in  damp  sheets,  he  Avas  seized  with  a  violent  sudden 
pain  on  the  right  side  which  obliged  him  to  take  to  his  bod.  He 
was  there  a  fortnight,  and  was  treated  with  mustard  plasters. 
He  coughed  up  a  good  deal  of  frothy  sputa,  and  was  a  little  de- 
lirious several  nights.  The  pain  then  shifted  from  the  riglit  side 
and  settled  in  the  left,  but  did  not  prevent  his  getting  to  work 
again,  a  month  after  the  first  attack.  His  work  has  not  been 
hard,  as  he  reckons  hardness,  and  he  has  kept  at  it,  with  a  chance 
day's  exception,  till  his  arrival  here  on  June  25th.  The  principal 
troubte  he  has  had  and  the  cause  of  his  being  off  work  sometimes, 
has  been  dyspnoea.  He  feels  pain  on  bending  forward  and  on 
draAving  a  deep  breath. 

On  auscultation  in  a  sitting  posture,  there  is  very  absolute 
dullness  of  the  lower  half  of  the  lateral  and  scapular,  and  of  the 
whole  infra-scapular  region  on  the  left  side.  The  rest  of  the 
thorax  is  resonant.  When  he  lies  on  his  belly  and  puts  the 
shoulders  below  the  level  of  the  chest,  hanging  his  arms  and 
head  down,  this  infra-scapular  region  becomes  more,  but  not 
quite,  resonant,  show^ing  that  the  cause  of  the  dullness  is  in  part 
at  least  due  to  fluid  which  shifts  about  by  the  force  of  gravity. 
Still  some  dullness  remains,  and  there  is  a  whifiling  sound  with 
inspiration  and  expiration.  And  in  the  lateral  region  the  dull- 
ness is  unchanged  by  any  posture. 

The  secret  history  appears  to  me  to  be  this — that  the  man 
was  seized  with  double  pleurisy,  worse  on  the  right  side  than 
the  left — that  the  treatment  relieved  it — but  that  the  left  side 
being  the  least  cared  for,  the  inflammation  spread  to  the  pul- 
monary tissue,  and  caused  its  insidious  condensation.  The  cause 
of  the  dullness  on  percussion  is  partly  fluid  which  is  affected  by 
gravitation,  partly  solidified  lung  which  is  not  so  altered  in  its 
position.  The  fluid  in  the  pleura  and  the  condensed  pulmonary 
tissue  have  mutually  kept  one  another  from  being  restored  to 
perfect  life. 

Such  is  the  most  ordinary  cause  of  those  exceptional  cases  of 
pleurisy  which  become  chronic. 

The  longer  they  have  lasted,  the  more  obstinate  usually  are 


200  PLEURISY. 

they  in  yielding.  As  respects  treatment,  you  will  find  on  the 
card  the  following,  which  may  be  considered  the  ''' jyrocessus 
integer,"  (as  Sydenham  calls  it)  of  such  cases: — 

June  25.     JEinpl.  CantJiaridis  {j5!^  poll  ices)  lateri. 
^     Misturse  potassse  nitratis  Sj, 

Tineturse  ferri  sesquicldoridi  "H^xv. 

tei'-  die. 

I^     Pilulce  hydrargyria 
Pulveris  acillse, 
Pidvcris  digitalis,  aa  gr.  jss. 

omni  node  et  mane. 

You  will  observe  that  the  medicinal  treatment  is  a  union  of 
destruction  and  construction ;  it  is  designed  to  alter,  as  far  as 
possible,  the  whole  habit  of  the  system — to  cause  by  destruction 
a  demand  for  new  material,  the  supply  of  which  is  guarantied 
by  the  iron.  The  mercury  causes  a  general  increase  of  meta- 
morphosis, the  waste  products  of  which  are  directed  to  the 
kidneys  by  the  squill  and  niter.  The  digitalis  tends  to  relieve 
congestion  by  increasing  the  activity  and  tone  of  the  blood- 
stream. So  that  by  a  union  of  virtues  the  combination  pre- 
scribed in  the  pills  will  rarely  fail  to  prove  a  powerful  diuretic. 

The  blister  which  has  been  put  on  the  side  will  probably  have 
to  be  repeated  once,  and  perhaps  again.  You  will  observe  how- 
ever that  I  shall  leave  a  considerable  interval  of  time  between 
each  blister.  I  shall  not  apply  first  one  on  the  side,  then  one 
on  the  scapula,  then  one  beneath  the  collar-bone,  stroke  upon 
stroke,  one  on  as  fast  as  the  other  comes  off.  This  is  not  an 
uncommon  practice;  and  the  object  of  it  is  to  save  time  by  get- 
ting the  two  or  three  needful  blisterings  over  as  soon  as  possible. 
I  do  not  myself  adopt  it :  and  I  will  tell  you  why ;  as  the  reasons 
give  a  very  good  example  of  the  restorative  system  of  medicine 
which  it  is  my  object  to  teach. 

The  action  of  vesicants  is  first  to  destroy  the  epidermis  and 
to  cause  the  exudation  of  a  fibrinous  serum  beneath  it.  Very 
probably  a  similar  but  more  remote  effect  is  produced  on  the 


PLEURISY.  201 

neighboring  tissue  of  the  pleural  sac.  Nevertheless  it  is  not  at 
this  stage  of  the  process  that  the  chief  benefit  accrues.  If  you 
Avatch  carefully  the  line  of  dullness  marking  the  upper  margin 
of  the  collection  of  fluid  in  the  chest,  you  will  find  that  it  falls — 
not  when  the  blistered  skin  is  full  of  liquid  and  is  discharging 
serum — not  when  the  counter-irritation  may  be  fairly  concluded 
to  be  at  its  height — but  after  it  is  all  over.  As  the  sore  heals, 
then  the  level  goes  down  with  the  greatest  quickness.  That  is 
to  say,  that  the  true  use  of  blisters  in  such  cases  is  to  start  a 
healing  process,  or  a  renewed  life  on  the  outside  skin,  in  order 
that  it  may  spread  to  the  neighboring  viscus  inside.  As  long 
as  this  influence  continues  to  be  exerted,  you  will  gain  no  time 
by  a  recommencement  of  the  process,  and  your  too  hurried  repe- 
tition of  blisters  would  add  to  the  patient's  distress,  without  con- 
ducing to  his  cure.  Wait  till  the  effect  of  one  blister  has  quite 
gone  off",  before  you  order  another. 

Another  case  of  pleurisy  which  has  occurred  this  week,  I  do 
not  cite  as  primarily  instructive  in  a  therapeutical  point  of  view  — 
for  it  was  rather  an  instance  of  the  weakness  of  our  art — but  as 
having  a  pathological  interest. 

Charles  D.,  aged  eight,  was  admitted  on  June  24,  with  pyremia 
after  scarlet  fever,  aff'ecting  the  principal  joints,  and  with  an  in- 
cipient slough  on  the  sacrum.  On  July  1  he  died.  At  the  re- 
quest of  the  parents  the  curator  cut  into  one  only  of  the  joints, 
and  that  was  tense  with  creamy  pus;  so  that  the  same  condition 
may  be  assumed  to  have  existed  in  all.  On  opening  the  chest, 
serum  filled  with  flakes  of  fibrin  gushed  out  from  the  right  pleura. 
Bands  of  soft,  elastic,  straw-colored  fibrin  of  an  inch  in  length 
united  the  opposite  sides  of  the  whole  pleura,  and  coated  the 
surfaces  with  a  honey-combed  layer.  The  lung,  pressed  back 
against  the  spine,  was  non-crepitant,  inelastic,  and  tough.  Now 
the  front  of  this  boy's  chest  had  been  examined  on  the  day  of 
his  admission  by  myself,  by  the  resident  medical  officer,  and  by 
the  clinical  clerk,  and  I  cannot  but  feel  sure  that  had  pleurisy 
existed  at  that  period  one  of  us  would  have  found  it  out.  After- 
wards, the  Availings  of  the  poor  child  at  the  idea  of  being  touched 


202  PLEURISY. 

became  so  piteous,  and  the  torture  of  moving  the  arms  would 
have  been  so  great,  that  an  examination  to  discover  the  cause  of 
the  pain  he  comphiined  of  in  the  side  was  out  of  the  question. 
The  exact  day,  then,  when  the  pleurisy  came  on  is  unknown, 
but  it  must  have  been  less  than  a  week  before  decease. 

What  an  amount  of  disorganization  to  have  happened  in  such 
a  short  time !  What  a  quantity  of  serum  and  fibrin  to  be  formed ! 
What  a  laying  waste  of  the  pulmonary  tissue !  We  all  acknowl- 
edge pyaemia  to  be  the  most  furiously  destructive  result  of  an 
idiopathic  poisoning  that  we  know;  but  yet,  before  seeing  such 
a  case  as  that  of  this  child,  we  should  scarcely  believe  the  swift- 
ness of  its  action  to  be  so  great  as  it  really  is.  Knowing  all  we 
do,  we  should  still,  I  think,  be  disposed  to  underrate  it. 

The  moral  is,  if  the  march  of  death  be  thus  hasty,  let  there 
be  no  delay  in  your  remedies.  Apply  your  cupping,  or  leeching 
(or  faute  de  mieux  venesection),  your  bedding  and  your  poul- 
tices, your  slops  and  your  diuretics,  Avithout  losing  a  minute. 
Do  not  leave  alone  patients  to  nature  in  any  disease ;  least  of  all 
in  acute  pleurisy,  when  really  acute  and  dangerous.  But  I  must 
warn  you  against  looking  upon  this  as  a  typical  case.  There 
was  present  in  the  body  that  frightful  poison  which  produces  the 
destruction  of  life  we  call  pysemia,  and  which  would  infallibly 
have  proved  fatal  some  other  way  had  it  not  been  so  by  pleurisy. 
The  really  typical  cases  are  those  which  I  described  at  the  be- 
ginning of  the  lecture  as  getting  well  by  employment  of  the  sim- 
plest restorative  means,  or  even  in  spite  of  their  neglect. 


LECTURE    XVII. 

HYDROTHORAX. 

Term  ^^ idiopathic  hydrothorax''  justified — Forms  of  yleuritic 
disease — Which  form  is  here  intended — Tivo  cases — Hydro- 
thorax,  a  collection  of  fluid  in  the  pleura — Difference  between 
collection  and  effusion — Source  of  the  fluid — Action  of  phy- 
sical agents  in  the  production  of  the  disease —  Treatment  foimded 
upon  the  pathology — Blisters — Poultices —  Mercury — Food — 
Digitalis — Squill — Niter — Scoparium — Sequel  of  the  second 
case,  Seven  months  afterwards — State  of  chest,  and  explanation 
thereof — Another  case  of  displaced  heart — Treatment  by  para- 
centesis— Large  quantity  drawn  off  ivithout  return  of  heart — 
Comparison  of  these  two  cases  as  to  treatment — Results  in- 
ferred from  them,  and  from  an  analogous  case  of  empyema 
opening  externally. 

{^Clinical,  St.  Mary' s,  November  22,  1861.) 

Two  cases  of  idiopathic  hydrotliorax  in  the  wards  shall  supply 
us  "with  instruction  to-daj. 

Idiopathic  "hydrothorax,"  or  "hydropleurisy,"  is  an  expres- 
sion which  I  find  requires  a  defence.  In  the  "  Cyclopaedia  of 
Practical  Medicine,"  and  in  the  "Library  of  Practical  Medi- 
cine," (whose  good  indices  render  them  the  most  frequent  books 
of  reference  for  busy  men),  the  existence  of  such  an  idiopathic 
state  is  denied  altogether.  Effusions  of  fluid  into  the  pleural 
sac  are  stated  always  to  depend  either  on  some  visceral  cause  of 
dropsy,  such  as  organic  changes  in  the  heart,  liver,  and  kidneys, 
or  to  consist  of  pus,  when  the  case  acquires  a  title  to  be  classed 
as  empyema.  An  acute  collection  of  serum  in  the  pleural  sac 
from  causes  depending  on  the  pleura  itself,   is  either   ignored 


204  HYDROTIIORAX, 

altogether,  or  merged  in  tlie  common  description  of  "pleurisy." 
This  I  hold  to  be  bad  pathology,  likely  to  lead  to  bad  practice. 
That  a  quantity  of  fluid  sufficient  to  fill  one  side  of  the  chest  to 
complete  dullness,  that  is  to  say  between  four  and  five  pints, 
should  disappear  in  ten  days  or  a  fortnight,  is  surely  conclusive 
against  that  fluid  being  pus.  Pus  is  absorbed,  if  absorbed  at  all, 
with  extreme  slowness. 

Then  as  to  the  undifferentiated  classification  of  these  cases  as 
"pleurisy," — is  that  practically  correct?  Let  us  examine.  Half 
of  our  pleuritic  patients  have  no  fluid  collected  at  all ;  there  is 
pain  in  the  side,  and  rubbing  sounds  on  auscultation  of  the 
roughened  surfaces,  but  no  dullness  on  percussion.  This  is 
^''pleurisy  imre^'  and  gets  well  fast  enough  when  treated  as 
such.  Then,  again,  there  are  very  severe  inflammations  where 
the  dullness  is  unfortunately  due  to  pus.  This  is  '■^pleurisy  tvith 
empyema,"  and  requires  the  empyema  to  be  treated  as  well  as 
the  pleurisy,  if  it  is  to  be  cured.  Then  there  is  a  third  class 
where  all  the  general  symptoms,  such  as  pain  on  inspiration, 
fever,  and  so  on,  are  accompanied  by  stethoscopic  signs  of  a 
moderate  collection  of  fluid,  but  whose  rapid  absorption  shows 
it  to  be  serum.  This  is  ^'■pleurisy  ivith  serous  effusion."  But 
the  serum  is  not  a  matter  of  importance;  it  causes  no  increase 
of  dyspnoea  beyond  what  is  due  to  the  pleurisy,  and  it  disap- 
pears without  any  special  treatment  when  the  pleurisy  is  cured. 
The  medical  attendant  is  wise  to  think  much  about  the  pleurisy 
and  little  about  the  serum. 

There  is  a  fourth  class,  to  two  examples  of  which  I  call  your 
attention  to-day,  where  this  condition  is  reversed,  where  the 
pleurisy  is  absent,  or  of  small  moment,  and  the  amount  of  serum 
is  great;  and  where  the  nomenclature,  if  it  is  to  be  of  use,  must 
indicate  this.  Here  the  practical  physician  feels  that  what  he 
has  to  attend  to  is  primarily  the  serum,  and  secondarily  only 
(if  at  all)  the  pleuris}^  and  he  requires  a  word  to  express  this 
state  of  things.  With  Laennec,  I  would  advise  adherence  to  the 
name  "idiopathic  hydrothorax,"  meaning  a  collection  of  serum 
in  the  pleural  sac  injurious  to  health  from  its  quantity,  and 
arising  from  an  abnormal  state  of  the  pleura  itself. 


IIYDROTHORAX.  205 

Case  1. — Maria  G.,  a  housemaid,  aged  twenty,  has  always 
enjoyed  sufficiently  good  health  to  continue  in  domestic  service, 
though  subject  sometimes  to  "bilious  headaches,"  to  pain  in  the 
hepatic  region,  sties  in  the  eye,  and  irregularities  in  the  cata- 
menia.  She  easily  catches  cold,  and  has  habitually  a  dry 
cough,  but  never  expectorated  blood  or  indeed  any  sputa  at 
all.  Her  father  died  at  forty  of  some  chest  complaint,  but  her 
mother  is  alive  and  well,  and  she  has  not  lost  any  collateral  re- 
lations in  adult  age.  In  short,  though  she  is  well  grown  and 
hearty  looking,  her  constitution,  perhaps  inherited  from  the 
paternal  side,  is  endowed  with  little  pow'er  of  resistance  to  ex- 
ternal influences.  She  is  just  the  sort  of  person  who  might 
through  force  of  untoward  circumstances  develop  tubercle  ; 
though  I  feel  sure  she  has  not  done  so  as  yet.  I  say  she  has 
not  done  so  as  yet,  because  such  a  constitution  as  hers  gives 
way  very  rapidly  when  once  disease  has  begun;  and  she  is  also 
very  sensitive,  so  that  she  would  be  sure  by  this  time  to  have 
shown  it,  did  any  internal  organic  lesion  exist. 

She  was  in  her  usual  health  up  to  October  27,  last,  and  had 
menstruated  naturally  the  week  before.  On  that  day  and  on 
the  28th,  without  any  assignable  cause,  she  felt  "giddy,  nerv- 
ous, and  ill;"  and  in  the  evening  of  the  28th  she  felt  a  difficulty 
in  breathing,  with  a  stabbing  pain  in  the  right  side.  The  sharp- 
ness of  the  pain  lasted  three  hours,  when  it  went  off,  and  was 
followed  by  Avhat  she  describes  as  an  "aching."  On  the  29th, 
she  went  to  a  neighboring  surgeon,  who  sounded  her  chest,  gave 
her  some  pills  and  medicine,  and  bade  her  call  again  in  a  week. 
From  that  time  up  to  her  entry  into  the  hospital  she  was  un- 
able to  work ;  the  dyspnoea  kept  on  increasing,  as  did  also  a  sen- 
sation of  tightness  round  her  waist;  she  lost  her  appetite,  and 
was  thirsty;  she  had  also  frequent  shiverings  during  the  week, 
but  cannot  fix  the  date  of  the  first. 

I  saw  her  first  on  November  6.  She  had  to  be  propped  up  in 
bed  from  the  orthopnoea  and  dyspnoea  under  which  she  labored. 
There  was  complete  dullness  of  the  whole  of  the  right  side  of  the 
chest,  except  a  small  piece  beneath  the  clavicle,  which  was  reso- 
nant as  compared  with  the  lower  part,  but  still  dull  as  compared 
14 


206  IIYDROTIIORAX. 

with  the  other  side.  In  this  part  alone  were  there  breath  sounds 
to  be  heard;  and  these  were  of  a  bronchial  character,  like  the 
noise  produced  by  blowing  in  and  out  through  a  stethoscope. 
The  pulse  was  small,  120.  The  tongue  Avas  quite  clean.  She 
was  ordered  I^  Filulw  hydrargyria  k^cillve^  aa  gr.  jss,  Pulveris 
digitalis,  gr.  ij,  in  j)ihdd  ter  die  cum  haustu  sequenti — ^  Po- 
tassse  nitratis,  gr.  xx,  Spij'itus  sethe^ns  nitriei,  TT|xx,  3Iist.  cam- 
phorse,  %] ;  and  a  poultice  was  continuously  applied  to  the  right 
side  of  the  chest.  Diet:  tivo  pints  of  beef-tea,  one  pint  of  milk, 
bread  ad  libitum. 

Nov.  8. — The  breathing  is  more  labored;  the  dullness  on  per- 
cussion reaches  higher;  the  pain  has  returned  to  the  right  side 
of  the  waist.  Applic.  cue.  cruentse  ad  .5viij,  lateri  dextro  ;  perstet 
in  usu  pilulse  et  haustus  ter  die. 

Nov.  9. — The  sense  of  tightness  and  pain  around  waist  are 
much  relieved  since  the  cupping.  Otherwise  there  is  no  change 
in  symptoms.     Add  to  diet  anotJier  pint  of  milk. 

Nov.  10. — The  same  report.     Emplastrum  cantharidis  lateri. 

Nov.  15. — The  gums  feel  sore,  but  do  not  look  so.  The  breath- 
ing is  decidedly  easier,  but  I  can  remark  no  diminution  in  the 
extent  of  dullness  on  percussion.  Omitte  pilulam  in  unam  diem. 
Add  to  diet  an  egg  and  rice  pudding. 

Nov.  16. — There  is  a  decided  improvement  in  the  breathing. 
She  can  lie  down  with  the  addition  of  only  an  ordinary  pillow 
to  the  bolster.  There  is  breathing  of  a  mixed  bronchial  and 
vesicular  character  over  the  whole  infra-clavicular  and  over  part 
of  the  mammary  region,  and  more  resonance  on  percussion.  No 
rales.  Resumat  jnlulam  bis  die.  Kj  Decocti  scoparii  ,5jss  ter 
die,  vice  haustus  nitri  jjrioris ;  repetatur  empl.  cantharidis. 

Nov.  18. — Chest  quite  resonant  in  front.  Beneath  the  scapula 
behind  there  is  dullness  on  percussion,  and  regophony.  The  gums 
are  not  sore,  but  there  is  a  mercurial  taste  in  the  mouth.  Perstet 
in  usu  pilulw  et  haustus.  Diet  ^^ simple,"  u'ith  mutton-chop  and 
two  pints  of  milk. 

Case  2. — Annie  M.,  wife  of  a  builder's  clerk,  aged  twenty- 
seven,  of  a  healthy  long-lived  family,  has  never  been  ill  since 
the  age  of  fifteen,  when  she  had  influenza  for  a  fortnight.     She 


IIYDROTIIORAX.  207 

has  once  boime  twins,  who  died,  but  she  has  two  living  chihiren, 
the  last  of  whom  was  born  May  23,  and  she  suckled  him  up  to 
October  14,  when  she  was  forced  to  desist  by  her  present  illness. 
This  illness  she  accounts  for  by  the  following  history: 

During  the  first  week  of  October  her  baby  had  an  arm  very 
sore  after  vaccination;  and  she  fed  him  from  the  left  breast  ex- 
clusively to  avoid  rubbing  the  tender  place.  To  soothe  the 
natural  crossness  of  the  infant  she  used  to  do  this  even  out  of 
doors,  and  once  when  so  engaged  under  a  tree  in  Kensington 
Gardens  she  felt  much  chilled. 

During  the  second  and  third  weeks  of  October  dyspnoea  gradu- 
ally came  on,  accompanied  by  an  uncomfortable  feeling,  by  de- 
grees amounting  to  pain,  in  the  cardiac  region,  so  that  she  told 
her  husband  she  felt  sure  something  was  the  matter  with  the 
heart.  She  positively  denies  having  felt  any  stitch  in  breathing, 
or  other  pain  in  the  side;  she  did  not  lose  appetite,  and  did  not 
experience  any  thirst,  or  other  signs  of  fever.  Her  complaint 
was  of  dyspnoea,  pain  in  the  heart  on  exertion,  and  a  dread  that 
she  was  going  into  a  consumption.  This  dread  was  increased 
by  the  coming  on  of  a  cough,  accompanied  by  much  expectora- 
tion of  glairy  matter. 

She  was  admitted  into  St.  Mary's  Hospital  on  November  1. 
On  examination,  the  whole  left  side  of  the  thorax  was  absolutely 
dull;  it  was  nearly  two  inches  by  measurement  larger  than  the 
right  round  the  lower  part  of  the  waist,  and  there  was  entire 
absence  of  breath-sounds.  The  heart  was  dislocated  from  its 
usual  place;  the  apex  could  not  be  distinctly  found  to  impinge 
anywhere,  but  the  general  pulsation  was  felt  partly  in  tlie  epi- 
gastrium, partly  behind  the  cartilages  of  the  right  ribs — not  at 
all  in  the  cardiac  region.  She  could  not  breathe  when  lying 
down,  and  the  inspirations  were  irregular,  shallow,  and  frequent. 
On  the  right  side  there  was  excessive  motion  of  the  ribs  and 
puerile  breathing.  The  sputa  consisted  of  transparent  mucus 
with  but  little  froth.  The  pulse  was  upwards  of  120,  sometimes 
irregular  and  intermittent.  The  appetite  was  natural;  there 
was  no  thirst,  and  the  tongue  was  clean. 

The  patient  was  ordered  "half  ordinary  diet,"  with  the  addi- 


208  IIYDIIOTIIORAX. 

tion  of  a  pint  of  beef-tea,  and  a  pint  of  milk  daily.  A  blister 
six  inches  square  was  put  on  the  left  side,  and  the  folloAving 
pills  and  draughts  prescribed: — I^  Pulv.  digitalis,  scillse,  pil. 
hydrargyria  aagr.  jss;  oivni  node  et  mane.  Potassse  tiitratis, 
gr.  XX ;  Spiritits  setheris  nitrici,  TT^xx,  Mist,  camphorse^  5j  ter  die. 

Nov.  4. — Her  breathing  is  equally  laborious.  The  sputa  is 
more  copious,  and  the  cough  increased,  probably  by  a  draught 
from  the  window  upon  her  bed.  Pulse  100,  weak.  No  change 
in  medicine.     Blister  repeated.     Add  a7i  egg  to  diet. 

Nov.  1). — The  breathing  is  easier  since  last  report,  and  the 
measurement  of  the  thorax  three-quarters  of  an  inch  less.  Add 
a  bottle  of  stout  to  diet. 

Nov.  11. — She  says  she  coughs  only  in  the  daytime,  when 
there  are  windows  and  doors  unavoidably  open  in  the  ward. 
She  lies  on  the  afiected  side  without  pain  or  inconvenience  to 
the  heart,  though  it  still  remains  dislocated.  Diet  ^'•simple," 
with  one  chop,  one  egg,  one  bottle  of  stout. 

Nov.  14. — Soft  and  distant  breath-sounds  with  inspiration  and 
expiration  under  left  clavicle. 

Nov.  15  to  18. — The  medicine  was  omitted,  and  effervescing 
draughts  with  prussic  acid  were  given  on  account  of  nausea  and 
vomiting,  which  did  not  come  on  after  eating,  but  occurred  the 
first  thing  in  the  morning,  when  the  stomach  is  empty. 

Nov.  18. — She  resumed  the  medicine  before  prescribed. 

Nov.  20. — There  is  very  little,  if  any,  diminution  of  dullness 
on  percussion  since  admission,  although  air  now  enters  the  upper 
lobe.  The  fluid  does  not  seem  to  have  been  continued  to  be  ab- 
sorbed since  the  14th.  Perhaps  this  non-diminution  of  dullness 
arises  from  the  partial  return  of  the  heart  to  its  place;  fur  the 
organ  can  now  be  felt  pulsating  behind  the  cartilages  of  the  left 
ribs  as  well  as  on  the  wrong  side  of  the  chest.  Pulse  100,  of 
good  power.  The  stout  caused  her  face  to  flush  after  dinner, 
so  it  is  left  off.  Other  diet  as  before.  ^  Pil.  hydrargyri,  gr. 
iij ;  Scillse,  Pulv.  digitalis,  aa  jj,  ter  die;  Potassoe  nitratis,  gr. 
XX ;  SpiritHs  setheris  nitrici,  TT|xx;  Misturx  camphor oe,  5J,  ter 
die;  repetatur  emplastrum  cantharidis. 

In  the  first  of  the  cases  I  have  narrated  (that  of  Maria  G.) 


HYDROTIIORAX.  209 

there  is  every  reason  to  believe  tliat  the  abnormal  state  of  the 
pleura  was  of  an  inflammatory  character.  The  pain  in  the  side, 
the  stitch  on  inspiration,  the  rigor,  the  loss  of  appetite  and 
feverishness,  all  support,  the  opinion  that  there  was  inflammation 
of  the  serous  membrane.  And  probably  there  was  fibrinous 
exudation  too,  as  there  usually  is  in  even  slight  pleurisy.  But 
this  attack  seemed  to  have  been  of  a  very  unimportant  character 
in  itself;  she  was  not  confined  to  bed,  and  the  excellent  prac- 
titioner whom  she  consulted  in  the  first  instance  "gave  her  some 
physic  and  pills,  and  told  her  to  call  again  in  a  week,"  so  little 
did  he  think  of  it  after  examination  of  the  chest.  It  was  of  an 
unimportant  character  in  itself,  but  it  led  to  results  which  might 
have  been  very  serious,  perhaps  fatal. 

In  the  second  case  there  is  nothing  that  you  can  set  down  as 
evidence  of  pleuritis.  The  patient  is  of  a  nervously  sensitive 
temperament,  very  susceptible  of  physical  or  moral  pain  and 
pleasure,  ■so  that  had  there  been  anything  disagreeable  to  feel 
she  is  not  likely  to  have  forgotten  it;  yet  she  most  positively 
avers  that  there  never  has  been  since  she  was  taken  ill  any  stitch 
in  the  side  or  catching  of  the  breath  in  inspiration ;  the  only 
pain  in  the  chest  at  all  being  that  arising  from  the  forcible  dis- 
location of  the  heart,  and  closely  connected  with  its  struggling 
palpitations.  There  was  no  rigor,  no  thirst,  furred  tongue,  or 
loss  of  appetite,  such  as  accompanies  pyrexia.  Yet  the  hydro- 
thorax  is  greater  in  extent,  and  is  rather  more  obstinate  against 
remedies  than  in  the  former  instance. 

We  have,  then,  got  so  far  on  with  the  pathology  of  idiopathic 
hydrothorax  as  to  be  able  to  say  that — 1st.  It  does  not  follow 
severe  pleurisy, — for  that  produces  pus  and  fibrin  in  quantity 
proportioned  to  its  intensity,  and  not  serum. 

2d.  It  sometimes  follows  slight  pleurisy,  as  probably  here. 

3d.  The  pleurisy  is  sometimes  so  slight,  that  it  may  come 
under  the  rule  de  non  apparentibiis. 

Yet  that  the  cause  of  the  hydrothorax  is  the  pleura  itself,  we 
can  hardly  doubt  when  we  find  all  the  other  viscera  painless, 
apparently  normal,  and  doing  their  duties  in  the  usual  manner. 
Moreover,  it  is  absorption,  a  function  of  the  pleura,  the  want  of 


210  IIYDROTIIORAX. 

which  truly  constitutes  the  disease.  You  must  not  let  the  com- 
monly used  but  deceptive  word  "effusion,"  mislead  you  into 
viewing  dropsical  fluids  as  products  of  extra  exertion  on  the 
part  of  the  sacs  which  contain  thera.  Like  all  morbid  phe- 
nomena, dropsical  fluids  are  proofs  of  sluggishness,  of  deficient 
vitality.  In  full  vigor  of  health,  the  pleura,  pericardium,  and 
other  similar  membranes  probably  pour  out  a  much  greater  quan- 
tity of  fluid  than  they  do  in  disease:  this  fluid,  in  the  normal 
state,  is  taken  up  again  by  absorption  as  soon  as  exhaled,  so 
that  on  opening  the  serous  sacs  we  find  them  damp,  indeed,  and 
dripping,  but  empty.  By  disease  absorption  is  stopped  or  at 
least  slackened,  and  the  natural  transudation  still  continuing,  a 
collection  of  its  products  remain  ensacked.  Think  of  dropsy  as 
a  coUection,  not  as  an  effusion,  and  your  pathology  will  be  right. 
Do  you  ever,  while  looking  in  a  dead  body  at  these  thin,  ap- 
pai'cntly  unimportant,  membranes — seemingly  only  the  sacs  as 
they  are  called — do  you  ever  reflect  on  the  business  they  trans- 
act when  they  are  alive?  The  experimental  observations  of 
physiologists  tend  to  assign  to  thera  an  activity  almost  incredible, 
and  pathologists  will  do  well  not  to  neglect  the  hint.  Professor 
Lehmann*  opened  the  pericardium  of  a  healthy  criminal,  and 
collected  the  fluid  which  ran  from  it  in  three  minutes  and  a  half. 
It  amounted  to  33-8  grammes  (9J  fluid  drachms).  If  always  ex- 
haled at  that  pace,  the  quantity  in  twenty-four  hours  would  be  a 
gallon  and  a  half  from  the  pericardium  alone ! — equal  to  about 
one-sixth  of  the  whole  weight  of  an  average  man.  This  in  a 
state  of  nature  would  be  immediately  reabsorbed;  and  lest  we 
might  hesitate  to  credit  the  serous  membranes  with  such  an 
enormous  power  of  endosmosis  as  well  as  exosmosis,  we  can  refer 
to  Dr.  Richardson'sf  experiments,  which  exhibit  this  power  in 
action.  This  physiologist  injected  into  the  peritoneum  of  a  dog 
weighing  23  lbs.  water  to  the  extent  of  4  lbs.,  or  more  than  one- 
sixth  of  its  weight.  Twelve  hours  afterwards  the  animal  gradu- 
ally sank,  and  was  examined  an  hour  after  death.  Not  a  trace 
of  fluid  was  found  in  the  peritoneum.     It  had  all  got  into  the 

*  Lehmann's  "Physiol.  Cheniie,''  ii,  309. 

f  Dr.  Richardson  on  the  '-Coagulation  of  the  Blood,"  Exps.  36,  37,  38,  39. 


IIYDROTIIORAX.  211 

veins,  and  caused  death  by  dilution  of  the  blood.  Three  repeti- 
tions of  the  same  experiment  produced  results  essentially  the 
same,  the  injection  of  a  quantity  of  water  equal,  or  nearly  equal, 
to  one-fifth  of  the  weight  proving  fatal  by  artificial  anfemia — not 
by  retention  of  the  fluid  in  the  serous  sac,  but  by  its  being  taker, 
into  the  circulation.  When  a  less  quantity  is  injected,  the  ani- 
mal recovers  in  about  three  days;  but  even  in  the  fatal  cases, 
the  serous  membrane  does  its  duty  in  taking  up  with  an  almost 
incredible  activity  the  water  presented  to  it. 

When  you  reflect  upon  the  activity  of  the  serous  membranes 
in  a  normal  state,  you  will  have  no  difficulty  in  understanding 
where  the  great  mass  of  fluid  comes  from  in  dropsies  of  the 
serous  sacs.  Nor  will  you  fail  to  see  whither  it  ought  to  go. 
And  then  you  will  clearly  see  that  the  disease  to  be  treated  is 
no  excess  of  life,  no  exaggerated  transudation,  but  a  defect  of 
life,  an  arrested  absorption. 

How  do  the  physical  agents  to  which  illness  is  traceable  beget 
the  varieties  of  pleural  disease  which  I  have  noticed  ?  When 
by  the  impression  of  cold,  or  by  direct  mechanical  injury,  an 
inflammation  of  the  pleura  is  produced,  with  great  congestion  of 
the  veins  at  first,  and  afterwards  with  a  copious  formation  of 
fibrin,  the  absorption  indeed  is  interfered  with  most  forcibly; 
but  yet  it  is  not  these  severe  pleurisies  in  which  you  have  the 
largest  collection  of  fluid.  The  reason  of  which  is  that  the  nor- 
mal exhalation  is  then  slackened  at  the  same  time.  But  it  is 
arrested  by  a  less  severe  impression  than  the  absorption  is;  and 
either  only  a  local  obstruction  of  the  absorbents  may  take  place 
by  a  local  formation  of  fibrin  or  by  congestion,  or  a  partial  arrest 
of  it  throughout  the  whole  area  by  a  force  unequal  to  the  pro- 
duction of  actual  inflammation.  In  each  case,  the  exudation 
remaining  nearly  normal  quickly  causes  a  copious  collection  of 
fluid.  The  reason  why  hydrothorax  is  not  more  common,  is, 
that  usually  the  arrest  of  the  exudation  is  contemporaneous 
with,  and  in  proportion  to,  that  of  the  absorption. 

On  this  pathology  is  founded  the  treatment.  The  aim  is  to 
restore  the  function  of  absorption,  and  to  that  end  our  remedies 
are  directed.     I  will  remark  upon  them  severally. 


212  IIYDROTIIORAX. 

Blisters. — I  will  not  insult  pupils  who  have  gone  through  a 
course  of  physiology  by  supposing  that  they  would  do  anything 
but  smile  at  the  vulgar  idea  that  blisters  do  good  by  "drawing" 
to  the  outside  the  fluid  from  the  inside  ;  for  it  must  be  obvious 
to  the  most  superficial  medical  student,  that  the  quantity  thus 
elicited  is  too  small  to  be  of  any  service.  But  still  perhaps  you 
may  not  have  clear  notions  as  to  their  real  action  ;  and  there- 
fore there  is  danger  of  your  sometimes  applying  them  wrongly. 
The  true  profit  to  be  got  out  of  cantharides  is,  in  the  first  in- 
stance, the  encouragement  of  absorption,  a  power  which  is 
exerted  over  fluids  and  solids  equally,  and  therefore  is  quite 
independent  of  the  evacuation  of  serum  by  the  cutis.  The  ex- 
planation of  the  steps  in  this  process  most  reconcilable  to  phy- 
siology, are  the  attraction  of  blood  towards  the  capillaries  of  the 
skin  in  the  first  place  ;  secondly,  its  dispersion,  and  the  conse- 
quent quickening  of  the  capillary  circulation  in  the  neighboring 
parts.  With  the  quickened  capillary  circulation  follows  in- 
creased endosmosis,  according  to  the  well-known  law,  that  the 
attraction  of  fluids  through  membranes  is  in  the  direction  of 
the  fluid  set  in  motion  and  proportioned  to  the  rapidity  of  the 
motion.  A  further  advantage  is  derived  from  the  renewal  of 
growth  which  is  entailed  on  the  tissues  by  the  self-renewing 
skin.  The  process  seems  to  be  propagated  to  surrounding  parts 
notwithstanding  dissimilarity  of  tissue. 

The  practical  knowledge  to  be  derived  from  this  physiological 
view  of  the  action  of  a  blister  should  teach  you  patience  in 
waiting  for  the  advantages  to  be  derived  from  it ;  for  they  are 
obviously  by  no  means  limited  to  the  period  of  its  application, 
but  rather  begin  after  it  is  removed,  and  continue  even  after  the 
sore  place  is  healed.  You  may  also  learn  by  this  view  of  its 
action  not  to  torture  your  patients  needlessly  by  keeping  the 
blister  on  too  long,  under  the  mistaken  idea  that  you  cannot 
have  too  much  of  a  good  thing. 

In  some  cases  I  do  not  even  allow  the  blister  time  to  raise  the 
scarf-skin,  so  that  I  may  have  an  opportunity  of  repeating  it  in 
the  same  place.  But  as  a  general  rule  I  think  the  detachment 
of  the  epidermis  desirable,  for  it  appears  to  me  that  absorption 


HYDROTIIORAX.  213 

is  particularly  active  during  the  growth  of  the  new  skin.  Per- 
haps the  capillary  circulation  is  quickened  by  the  demand  for 
new  material  entailed  by  new  groAvth,  and  perhaps  the  industry 
of  increased  life  may  spread  to  the  neighboring  absorbents  and 
solid  tissues.  Whatever  the  explanation  may  be,  the  fact  is  that 
during  the  healing  of  a  blistered  surface  its  chief  benefits  are  to 
be  found. 

Next  in  power  to  blisters  come  poultices.  Their  action  in  a 
great  measure  depends  on  the  continued  moist  ■\^^armth  acting 
on  di-osmotic  processes  according  to  the  law  of  their  augmen- 
tation by  heat.  But  it  is  also  partly  in  a  more  special  manner 
vital;  for  the  skin  is  reddened,  swelled,  and  made  more  delicately 
sensitive  by  their  application.  They  are  useful  in  pleurisies  and 
moderate  collections  of  fluid,  Avlien  their  size  needs  to  be  mode- 
rate only  ;  but  it  is  inconvenient  to  keep  the  whole  side  covered 
up  with  a  poultice,  and  if  they  are  not  constantly  put  on  hot 
and  hot,  the  surface  is  apt  to  get  chilled. 

Mercury  distances  all  the  contents  of  our  pharmacopoeia  in 
the  power  of  hastening  destructive  metamorphosis.  Under  its 
influence  all  the  excretions  are  increased  at  the  expense  of  the 
tissues.  It  is  quite  true  that  by  such  a  process  nothing  is  di- 
rectly gained  in  cases  like  those  before  us:  there  is  no  poison  to 
evacuate,  and  the  debility  which  follows  is  so  much  ground  lost. 
Harm  certainly  is  done  by  it,  but  with  the  harm  is  joined  a  good 
which  I  think  is  worth  the  loss.  Nothing  so  consistently  and 
steadily  aids  absorption  as  mercury,  and  nowhere  can  you  trace 
its  eff'ects  so  easily  as  in  hydrothorax.  In  the  history  of  both 
these  cases  you  may  observe  that  no  immediate  improvement 
follows  the  ingestion  of  the  remedy;  but  that  immediately  on  its 
pathogenetic  effects  being  produced,  immediately  on  the  gums 
becoming  tender,  the  dispersion  of  the  fluid  can  be  tested  by 
relief  to  the  breathing  and  commencing  resonance  on  percussion. 
And  from  this  point  a  steadily  advancing  progress  is  made  to 
recovery. 

I  would  wish  you  to  remark  that  the  relief  to  the  dyspnoea 
has  preceded  by  a  short  time  the  return  of  resonance,  especially 
in  the  woman  whose  hydrothorax  is  on  the  left  side.     The  reason 


214  IIYDROTIIORAX. 

is  that  when  a  certain  quantity  of  fluid  is  removed,  the  emptied 
space  is  filled  up  in  both  instances  by  the  re-expanding  lung, 
and  in  the  left  side  by  the  return  also  of  the  dislocated  heart. 
It  is  necessary  to  note  this  in  order  to  trace  correctly  the  period 
■when  the  remedy  begins  to  work. 

When  absorption  is  once  set  agoing,  it  is  not  necessary  to 
continue  the  full  doses  of  mercury;  if  any  evil  accrues  from  it, 
you  may  leave  it  off  altogether;  for  its  benefi^cial  effects,  like 
those  of  blisters,  may  be  calculated  upon  as  likely  to  continue 
after  its  intermission. 

And  you  may  also  avoid  the  injury  liable  to  accrue  from  the 
destructive  drug  by  amply  supplying  the  materials  to  take  the 
place  of  the  loss.  Be  very  careful  that  your  patient  has  food  in 
the  most  frequent  doses  possible,  in  the  largest  doses  that  will 
not  give  nausea,  and  in  the  forms  most  easily  digested.  You 
have  seen  this  aimed  at  in  the  dietaries  of  the  cases  under  your 
notice,  on  principles  which  I  need  not  again  recount. 

Digitalis,  squill,  and  niter  were  ordered  for  their  diuretic 
qualities  only.  That  they  all,  both  separately  and  combined, 
increase  the  quantity  of  the  urine,  is  established  by  observation; 
and  that  such  action  is  beneficial  in  dropsies,  is  a  traditional 
belief.  For  my  part  I  have  no  reason  to  doubt  it,  for  I  remember 
as  a  student  to  have  seen  patients  recover  in  whose  treatment 
the  diuresis  was  the  only  therapeutic  agent  that  I  could  at  all 
reconcile  with  rational  physiology.  Diuretics  do  not  promote 
absorption  in  the  same  manner  as  mercury,  by  the  hastening  of 
destructive  metamorphosis.  The  experiments  collected  by  Dr. 
Parkes"^  show  that  though  the  water  of  the  urine  is  augmented, 
yet  that  the  daily  excretion  of  urea  is  either  diminished  or  un- 
affected, thus  proving  that  at  least  one  great  class  of  the  con- 
stituents of  the  body,  namely,  the  nitrogenous,  are  exempted. 
This  CMiisidevation  has  an  important  bearing  on  practical  medi- 
cine, for  it  allows  us  freely  to  administer  these  reagents  com- 
bined with  mercury,  without  fearing  that  we  shall  thereby  add 
to  the  unavoidable  evils  of  that  mineral. 

Scoparium. — The  most  memorable  example  to  my  own  mind 

*  "Parkes  on  Uriue,"  pp.  158,  170,  173. 


HYDROTIIORAX.  215 

of  the  good  effects  of  broom-tops,  is  that  of  the  followino;  case 
in  which  I  differed  in  opinion  with  a  patient,  and  when  he  was 
right  while  I  was  wrong.  A  poor  fellow  Avith  slowly  growing 
malignant  disease  of  liver  and  peritoneum  was  taking  under  my 
orders  this  remedy  for  the  ascites  caused  by  the  abdominal 
tumors.  It  still  increased,  and  pressed  upwards  the  diaphragm 
so  much  that  I  wished  the  peritoneum  to  be  tapped.  lie  flatly 
refused  to  submit  to  the  operation,  and  so  of  course  ceased  to 
be  a  patient  of  mine.  About  six  months  afterwards  he  came  to 
me  again  with  an  extension  of  cancer  to  the  costal  periosteum, 
of  which  he  shortly  afterwards  died.  To  my  surprise  I  saw  his 
ascites  was  all  gone,  and  inquired  who  had  cured  it.  He  stated 
that  he  had  continued  the  use  of  broom-tea  for  two  months  after 
his  dismissal  from  my  care,  and  that  during  that  time  his  abdo- 
men was  reduced  to  its  natural  size,  and  had  not  again  swelled. 
Surel}''  a  course  of  treatment  under  which  dropsy  due  to  in- 
creasing malignant  tumors  has  got  well,  must  have  no  ordinary 
power. 

Besides  acting  as  a  diuretic,  broom  has  the  additional  advan- 
tage of  giving  an  appetite  by  the  bitter  which  it  contains. 


{Clinical,  St.  Mary's,  June  21,  1862.) 

During  my  visit  a  few  days  back  a  young  married  woman, 
Annie  M.,  about  whom  I  gave  a  clinical  lecture  on  hydrothorax 
at  the  end  of  last  November,  was  sitting  in  the  ward.  You  may 
remember  that  then  her  chest  was  filled  with  fluid  and  the  heart 
pushed  over  to  the  right  side.  She  did  not  come  for  advice, 
but  to  thank  me  and  show  her  chest,  which  I  was  curious  to 
know  the  state  of.  We  found  that  the  heart  had  returned 
wholiy  to  its  natural  site,  and  that  there  was  to  be  heard  vesi- 
cular brciithing,  mixed  with  a  few  occnsional  crackles,  through- 
out the  pulmonary  tissue.  So  it  is  clear  that  the  lung  has  ex- 
panded, lets  in  air,  and  does  its  work.  Ic  has  expanded,  but  it 
has  not  expanded  to  its  full  size,  nor  does  it  do  all  the  work  it 
ought.    For  on  percussion  the  part  below  the  clavicle  is  still  dull, 


21G  IIYDROTIIORAX. 

and  is  flatter  than  the  opposite  side,  and  the  left  ribs  do  not 
open  out  with  inspiration  so  well  as  the  others.  I  have  no  doubt 
that  from  lonii;  compicssion  the  Inns;  tissue  has  partially  de- 
generated, and  tbat  it  will  be  months,  perhaps  years,  before  it 
recovers  its  full  life.  Iler  occupation  of  nursing  a  sick  husband 
is  not  tlie  most  favorable  one  for  regaining  vitality,  but  still  you 
see  her  in  as  fair  a  way  to  do  so  as  can  be  expected  under  the 
circumstances. 

Over  and  above  the  possible  degeneration  of  the  tissue,  there 
may  be  another  cause  for  the  dullness  on  percussion.  I  pointed 
out  to  your  notice  in  the  wards  a  week  or  two  ago  a  vessel  of 
serous  fluid,  which  had  been  drawn  off  by  paracentesis  from  the 
thorax  of  a  patient  of  Dr.  Sibson's.  It  was  transparent,  straw- 
colored,  and  not  perceptibly  reddened  by  blood.  In  the  center 
of  the  porringer  floated  a  delicate  fibrinous  clot,  just  such  as 
forms  in  blood,  but  wanting  the  red  globules.  It  was  coagulable 
fibrin  that  had  coaorulated  after  beino;  drawn  oflT.     Now  if  this 

O  c5 

fibrin  should  collect  and  be  coagulated  inside  the  pleural  sac,  it 
clothes  the  lung  with  a  strong  coat  which  impedes  its  expansion; 
and  if  it  form  also  a  layer  over  the  costal  pleura,  each  fibrinous 
mass  would  separately  produce  partial  dullness  on  pei-cussion, 
without  the  pulmonary  tissue  being  seriously  the  worse  for  it. 

I  am  glad  Annie  M.  came  to  show  herself  just  now,  as  you 
have  under  your  eyes  a  case  very  similar  to  hers,  Avhere  a  some- 
what difl'erent  treatment  has  been  pursued. 

James  S.,  a  tall  and  muscular  day -laborer,  aged  twenrysix, 
was  admitted  May  30,  1862.  For  nearly  a  year  he  had  found 
his  breath  short,  but  was  not  so  seriously  hampered  by  it  as  to 
be  oblige<l  to  give  up  work,  till  last  Christmas.  Shortly  before 
that  date  he  says  he  remembers  observing  that  his  heart  beat  on 
tlie  right  side  of  the  chest  instead  of  the  left.  That  symptom 
was  certainly  veiy  conspicuous  on  his  admission ;  you  could  not 
hear  or  feel  a  trace  of  heart-strokes  except  on  the  right  of  the 
median  line,  and  there  they  were  very  strong  and  loud.  So  one 
can  easily  conceive  its  having  been  remarked  even  by  an  unpro- 
fessional person.  There  was  an  entire  absence  of  breath-sounds 
on  the  left  side,  which  also  was  absolutely  dull  on  percussion. 


IIYDROTIIORAX.  217 

Several  careful  examinations  on  successive  days  by  different 
parties  made  sure  of  the  fact  that  the  left  side  was  not  in  the 
least  dilated,  eighteen  inches  from  median  line  to  spinous  process 
being  the  exact  measure  of  the  semi-circumference  of  the  thorax 
on  the  left  and  right. 

lie  is  a  hearty  strong  man  with  the  exception  of  dyspnoea,  and 
appears  to  have  no  other  disease  about  him  beyond  that  of  the 
pleura. 

He  was  at  first  treated  with  the  diuretic  pill  (^Pil.  hydrargyria 
pulv.  digitalis,  scillse,  aa.  gr.  jss)  every  night  and  morning,  a 
draught  containing  niter  and  iodide  of  potassium  three  times  a 
day,  and  a  large  blister  to  the  side.  But  after  a  week  of  this 
treatment  no  ground  seemed  gained,  no  respiration  was  to  be 
heard  In  any  part  of  the  left  lung,  and  the  heart  seemed  if  any- 
thing rather  more  over  to  the  right  side  than  before.  He  him- 
self thought  that  the  dyspnoea  was  increased.  I  therefore  tapped 
the  chest  Avith  a  small  trocar  between  the  fifth  and  sixth  ribs  in 
the  lateral  region,  and  drew  off  sixteen  fluid  ounces  of  fluid,  and 
then  continued  the  same  treatment  as  before,  to  try  and  en- 
courage absorption. 

The  fluid  drawn  was  a  yellow  serum  slightly  opalescent. 
After  standing,  it  deposited  some  of  the  gray  opaque  matter 
which  caused  its  opalescence.  The  opaque  matter  examined 
under  the  microscope  was  seen  to  consist  of  fine  granules,  irre- 
gularly conglomerated  into  globules  of  various  sizes.  The 
application  to  it  of  acetic  acid  did  not  exhibit  the  presence  in 
those  globules  of  any  nucleus,  but  rather  dissolved  them,  and 
rendered  them  still  less  like  pus  than  they  were  previous  to  its 
application. 

My  own  impression  is,  that  the  granular  matter  is  fibrin, 
altered  by  long  soaking  in  serum — the  same  fibrin  in  fact  which 
I  showed  you,  showing  signs  of  recent  life  by  coagulating  into 
a  clot,  in  the  fluid  drawn  from  Dr.  Sibson's  recent  case  ;  but 
which  has  become  by  time  dead  and  unable  any  longer  to  coagu- 
late. It  is  the  fibrin  which  is  exhibited  in  ordinary  blood-serum, 
and,  after  exuding  through  the  coats  of  the  vessels,  is  still  found 
in  the  more  watery  serum  of  serous  sacs. 


218  IIYDROTIIORAX. 

On  the  (lay  of  the  operation  there  was  some  bronchial  breathing 
to  be  heard  beneath  the  left  scapula,  but  the  dullness  of  the  left 
chest  on  percussion,  and  the  dislocation  of  the  heart  were  un- 
affected. 

Two  days  after  that  I  could  not  hear  even  the  bronchial 
breathing,  and  the  patient  seemed  in  no  better  case  than  on 
admission. 

Four  days  after  the  first  tapping  he  was  tapped  again  to  the 
extent  of  eighty-eight  fluid  ounces.  After  this  breath-sounds 
were  to  be  heard  very  distinctly  in  the  lower  lobe,  but  not  in 
the  upper. 

On  the  18th  of  June  the  diuretics  were  left  off,  and  the  fol- 
lowing prescription  was  ordered: 

I^  Quinse  et  ferri  citratis  gr.  v.  cum  oJei  morrhuse  5ij-  t^f  die. 

Though  the  diuretics  seemed  to  be  doing  no  positive  harm, 
yet  I  thought  it  possible  that  tonics  would  do  him  positive  good, 
and  ordered  them  as  above  described. 

He  was  allowed  to  have  full  meat  diet,  and  also  to  get  up  and 
walk  about ;  for  I  have  noticed  that  absorption  will  often  take 
place  quicker  when  the  patients  are  in  the  erect  posture  than 
when  they  are  confined  to  bed. 


[Case  continued  in  a  subsequent  lecture^  Juhj  19,  1862.) 

One  would  have  thought  that  enough  liquid  had  been  drawn 
from  James  S.  to  allow  the  heart  to  return  to  its  place.  But  it 
was  not  so.  On  the  6th  of  July,  five  weeks  after  admission,  he 
was  punctured  again  and  fluid  let  out  to  the  amount  of  forty- 
four  fluid  ounces.  He  has  also  had  the  chest  painted  with  iodine 
to  encourage  absorption.     But  the  heart  has  not  come  back. 

This  advantage  only  is  gained,  that  the  pulmonary  tissue  has 
been  gradually  returning  to  its  allegiance;  there  is  very  fair 
breathing  beneath  the  scapula  and  some  in  the  lateral  and  in 
the  supramammary  regions. 

You  may  have  remarked  that  the  lung  remained  dull  after 
each  tapping,  although   the    breath-sounds   increased.      This   I 


HYDROTIIORAX.  219 

conceive  to  be  due  to  a  layer  on  the  pleura  of  that  jfibrin  which 
I  have  pointed  out  to  you  as  a  natural  constituent  of  the  serum 
in  both  the  recent  and  more  chronic  forms  of  hydrothorax.  I 
believe  the  abnormal  coating  binds  down  the  lung,  preventing 
its  expansion,  and  counteracting  the  remedial  action  of  the 
operation.  So  that  much  less  than  you  might  have  expected 
has  been  gained  by  it,  and  the  patient  remains  on  hand  as  long 
as  the  young  woman,  Annie  M.,  whom  I  showed  you  in  the  ward 
and  lectured  about  a  month  ago,  and  who  was  not  tapped.  In 
fact,  the  chest  refuses  to  be  hurried  by  violence  and  must  take 
its  own  time. 

I  say  this  not  to  discourage  you  from  practising  the  operation 
of  paracentesis;  for  it  is  an  easy,  safe  operation,  and  in  recent 
cases  very  effective;  but  simply  to  prevent  your  disappointment 
in  case  you  should  anticipate  too  immediate  benefit  therefrom 
in  chronic  collections  of  fluids. 

As  an  experiment  upon  the  heart,  I  have  had  James  S.'s  chest 
bound  up  with  a  stout  tight  bandage,  as  if  the  ribs  were  fractured. 
The  design  is  to  make  the  bony  parieties  of  the  thorax  a  fixed 
point,  so  that  the  healthy  right  lung  may  compress  the  heart  by 
its  expansion  ;  and  as  it  moves  more  than  the  left  imperfect  lung 
by  reason  of  its  healthiness,  it  may  possibly  assist  in  reinstating 
the  displaced  organ.  All  I  can  report  upon  the  experiment  as 
yet  is  that  it  seems  to  do  no  harm,  but  I  cannot  say  it  does  any 
good. 

The  patient  also  continues  his  tonic  treatment,  and  I  think 
that  each  time  I  listen  the  breathing  in  the  lower  lobe  is  more 
distinct.  The  upper  lobe  expands  much  more  slowly.  I  suppose 
the  diaphragm  has  not  the  same  power  over  it  to  draw  the  air 
in,  and  so  we  find  only  an  indistinct  distant  breathing  in  that 
part. 

You  will  probably  ask  what  is  likely  to  be  the  result  of  this 
case.  In  answer  I  refer  to  that  of  Annie  M.,  which  was  exactly 
similar  to  that  of  James  S.*     I  may  refer  also  to  another,  not 

*  Shortly  afterwards  this  man  wished  to  return  to  work.  I  did  not  dissuade 
him,  as  he  was  able  to  run  up  stairs  without  dyspnoea,  and  felt  sure  he  would 
be  able  to  earn  a  fair  day's  wages.  The  heart  however  remained  beating  on  the 
right  side.     I  have  not  heard  of  him  since  then.     [October,  1863.) 


220  IIYDROTHORAX. 

indeed  of  lijdrothorax,  but  of  a  disease  whose  mechanical  re- 
lations to  the  chest  are  closely  analogous,  empyema  thoracis. 

An  old  patient  of  mine,  formerly  a  horse-jockey,  aged  now 
fifty-four,  is  occasionally  to  be  seen  about  the  streets  near  here, 
whose  chest  presents  a  striking  instance  of  the  form  which  con- 
tracted ribs  assume.  It  is  a  case  of  empyema  after  pleurisy, 
which  occurred  in  this  hospital  in  1857,  and  is  reported  by  the 
then  house-surgeon,  Mr.  Ash,  in  the  "Lancet"  for  May  31, 
1862.  The  empyema  was  cured  in  the  only  mode  in  which  it 
can  be  cured,  namely,  by  the  external  discharge  of  the  pus. 
Thus  the  chest  was  put  into  the  same  relative  mechanical  con- 
dition as  is  that  of  the  patient  now  in  the  wards  upon  whom  I 
am  lecturing.  The  heart,  which  had  been  displaced  to  the  right 
side  for  two  months,  returned  to  its  place  in  about  a  month. 
After  that  the  ribs  fell  in,  and  became  flattened  very  gradually, 
so  that  they  did  not  attain  their  utmost  flattening  till  the  autumn 
of  1859,  two  years  after  the  empyema.  And  then  how  were 
they  flattened? — not  in  the  part  where  the  empyema  had  heen, 
and  whence  it  had  been  discharged — not  in  the  lower  part  of 
the  thorax — but  beneath  the  cUivicle,  which  is  so  depressed  that 
the  man  looks  quite  lopsided  as  he  walks. 

I  fully  expect  the  ribs  of  our  present  patient  will  fall  in  after 
the  same  fashion,  and  that  his  heart  will  in  due  course  of  time 
get  back  to  the  right  place,  but  that  as  the  displacement  has 
lasted  longer,  so  that  the  restoration  will  be  longer  about. 

It  may  be  remarked  further,  that  in  the  lop-sided  old  jockey 
the  ribs,  though  flattened,  move  freely  and  equally  on  both 
sides  with  the  breathing,  and  that  the  air  enters  the  two  lobes 
of  the  lung  on  the  formerly  afi"ected  side  fully  and  equally. 
This  is  a  cheering  observation;  it  encourages  us  to  prophecy 
that  our  present  patient  also  will  with  time  recover  the  full  use 
of  his  lungs. 


LECTURE    XYIII. 

ACUTE    LARYNGITIS.  * 

Case — Important  point  in  the  pathology  of  the  disease  is  its 
locality — Tracheotomy  must  not  be  represented  as  a  last  hope — 
Reasons  for  delaying  it  and  reasons  for  not  delaying  it — Care 
of  digestive  organs —  Wine — Solid  food — Antimony — Mercury 
— Laryngitis,  acute  and  chronic,  and  their  difference  in  pa- 
thology and  in  principles  of  treatment. 

[Clinical,  St.  Marys,  October  25,  1861.) 

Maria  F.,  aged  twenty-two,  a  domestic  servant,  was  placed 
under  my  care  a  fortnight  ago.  It  appeared  that  she  came  first 
as  an  out-patient,  with  a  catarrlial  cokl  of  head  and  chest  of  a- 
few  days'  duration.  But  she  found  so  much  difficulty  in  breath- 
ing that  on  the  second  day  of  her  attendance  she  could  not 
leave  the  hospital,  and  Avas  sent  up  to  bed.  She  was,  when  first 
seen  (on  October  12),  cold  and  shivering,  her  face  was  livid, 
her  pulse  weak,  her  breathing  labored,  noisy,  and  spasmodically 
irregular.  There  was  also  slight  fullness  of  the  throat  and  ten- 
derness on  pressing  the  upper  part  of  the  larynx.  She  was 
ordered  inhalations  of  hot  steam,  and  frequent  teaspoonfuls  of 
hot  beef-tea  and  wine ;  four  leeches  were  applied  to  the  trachea, 
and  a  draught  of  an  ounce  of  decoction  of  cinchona,  and  a 
drachm  of  compound  tincture  of  cinchona,  ordered  to  be  taken 
every  alternate  hour. 

Next  day,  October  13,  it  is  reported  in  the  clinical  case-book 
of  Mr.  Young,  the  house  surgeon  : 

"  She  passed  a  very  bad  night.     The  dyspnoea  is  increasing  ; 
but  she  was  able  to  swallow  till   11  A.M.,  with  difficulty.     The 
throat  is  more  tender.     She  is  obliged  to  be  propped  up  in  bed, 
15 


222  ACUTE  LARYNGITIS. 

as  she  could  not  breathe  in  any  other  position.  There  is  slight 
cough,  the  face  is  flushed,  the  lips  livid,  the  eyes  swollen,  and 
countenance  anxious.  These  symptoms  gradually  increased  till 
7.30  P.M.,  when  she  Avas  found  gasping  for  breath,  and  asphyxia 
was  fast  coming  on,  when  a  little  chloroform  was  administered, 
and  Mr.  Young  performed  tracheotomy.  After  the  operation, 
the  pulse  was  100 ;  she  Avas  able  to  swallow,  and  expressed  her- 
self greatly  relieved. 

"  Oct.  14. — She  could  not  sleep  very  well.  She  took  a  little 
nourishment.  The  breathing  was  tranquil.  She  was  ordered  to 
have  an  enema  of  mutton-broth,  with  ten  minims  of  laudanum 
every  three  hours  ;  and  also  as  much  nourishment  as  she  could 
take  by  the  mouth. 

"  Oct.  15. — She  slept  pretty  well.  Pulse  100.  Tongue  furred. 
Slight  cough.     She  breathes  a  little  through  the  nostrils. 

''  Oct.  16. — The  trachea  and  larynx  are  not  so  tender.  Pulse 
98. 

"  Oct.  17. — The  tube  was  withdrawn,  and  she  breathes  tran- 
:juilly.  The  bowels  have  not  acted  since  the  operation.  A 
simple  enema  was  ordered  at  bed-time.  Her  appetite  is  very 
fair;  she  is  able  to  take  three  eggs,  beef-tea,  &c.,  in  addition  to 
enemata  of  mutton-broth. 

"Oct.  18. — The  bowels  acted  freely.  The  wound  is  granu- 
lating a  little.  Air  still  passes  through  the  opening,  which  is 
covered  by  a  piece  of  muslin  gauze. 

"  Oct.  19. — She  is  cheerful.  Tongue  clcaninn;  at  edges,  but 
still  very  much  furred  in  center.     Pulse  95. 

"Oct.  21. — Pulse  natural.  She  sleeps  tolerably  well.  She 
lias  slight  cough,  and  expectorates  a  little. 

"Oct.  23. — The  appetite  improves.  She  was  ordered  to  have 
half  a  dozen  oysters  daily  in  addition."* 

****** 

Inflammatory  laryngitis  (or  rather  glottitis)  is  a  disease  in 
which  the  power  we  wield  of  saving  existence  by  restoring  a  de- 
ficient function  is  most  strikingly  exhibited.  What  a  paltry  scrap 

■^  The  wound  healed  on  October  28,  and  on  November  4,  she  was  employed 
in  assisting  the  nurses  in  their  care  of  the  sick. 


ACUTE  LARYNGITIS.  223 

of  flesli  is  damaged  !  Yet  liow  frightful  the  results  are  to  wit- 
ness !  The  question  of  life  or  death  is  a  question  of  an  eighth 
of  an  inch  more  or  less  diameter  in  a  tube.  If  the  same  amount 
of  inflammation  were  in  your  finger  or  at  the  end  of  your  nose, 
anybody  would  laugh  at  you  for  going  to  a  doctor  about  it;  if 
it  were  in  your  digestive  canal,  you  would  perhaps  stay  away 
from  lecture,  and  take  some  slops,  but  you  would  not  care  to 
make  an  accurate  diagnosis  of  its  Avhereabouts.  Catarrhal  in- 
flammation may  even  attack  the  lower  part  of  the  larynx  itself 
pretty  severely,  and  yet  what  one  may  call  "old  nursey"  prac- 
tice be  all  that  is  required.  A  girl  in  an  adjoining  bed,  who 
came  in  at  the  same  time  as  this  one,  had  lost  her  voice  from 
the  tumefaction  of  the  vocal  cords,  yet  I  did  not  think  it  worth 
wliile  to  treat  her  further  than  by  keeping  her  in  bed  with  hot 
water  inhalations  and  ammoniated  salines.  But  once  let  inflam- 
mation sink  through  the  mucous  membrane  of  the  glottis  to  its 
submucous  tissue,  let  that  become  anasarcous,  and  you  see  what 
a  piteous  call  for  active  interference  arises!  I  say  like  ^schy- 
lus,  "you  Hce"  the  call,  because,  though  the  patient  has  all  the 
appearance  of  screaming  loudly,  and  mayhap  is  trying  to  do  so, 
no  cry  reaches  your  ears.  It  matters  not  if  the  inflammation 
be  violent  or  weak,  be  rapid  or  slow — directly  it  has  caused  the 
edges  of  the  glottis  to  swell  to  the  point  of  not  admitting  as 
much  air  as  the  lungs  want — instantly  that  it  has  reached  this 
point,  life  is  in  immediate  danger.  It  matters  not  what  was 
the  former  state  of  the  patient — the  present  moment  is  a  present 
and  pressing  peril — a  Samson  or  a  Lazarus  equally  hovers  on  the 
edge  of  the  grave. 

In  point  of  fact,  the  importance  of  acute  laryngitis  depends 
not  on  the  degree  of  injury  to  life,  but  on  the  localization  of  the 
disease.  And  hence  the  value  of  remedies  is  closely  proportioned 
to  the  special  definiteness  of  their  action  on  the  part  afiected. 
There  may  be  perhaps  in  the  druggist's  shop  excellent  remedies 
for  inflammation,  which  would  act  most  powerfully  all  over  the 
body  of  your  patient — all  over  the  body  of  an  animal  of  three 
times  the  size ;  but  you  do  not  want  just  now  to  act  all  over 
her  body,  only  on  that  little  spot  which  stands  between  her  and 


224  ACUTE  LARYNGITIS. 

life.  Do  not  run  the  chance  of  acting  deleteriously  on  the  whole 
person  for  the  sake  of  a  possible  benefit  to  such  a  minute  por- 
tion of  it.  Do  not  mistranslate  from  Hippocrates,  '•''extremis 
morhis  extrema  remedia^'''^  and  ransack  your  brains  for  that 
which  is  the  extremest  remedy  for  this  extremely  dangerous  in- 
flammation ;  but  seek  for  that  which  will  get  nearest  to  the  seat 
of  peril.  When  this  woman  came  into  the  ward,  she  was  (as 
described  in  the  report)  blue  in  the  face,  speechless,  incapable 
of  swallowing  and  breathing  without  labor  and  noise.  It  was 
very  obvious  that  something  must  be  done  to  relieve  her  with- 
out delay.  But  her  skin  was  cold,  her  pulse  was  weak  and 
quick,  and  she  was  worn  out  by  want  of  food  and  weariness. 
Wherefore,  though  I  expected  tracheotomy  would  have  to  be 
practiced,  I  thought  it  well  to  try  other  measures  first,  especi- 
ally as  there  are  other  measures  equally  local  and  equally  im- 
portant without  being  so  alarming.  I  got  her  warm  in  bed,  gave 
her  teaspoonfuls  of  hot  beef-tea  and  wine,  made  the  air  damp 
and  soft  round  the  mouth  with  hot  steam,  and  put  four  leeches 
on  the  outside  of  the  trachea.  There  was  some  degree  of  relief 
from  this,  and  the  purple  hue  of  the  face  wore  away  during  the 
afternoon.  But  the  next  evening  it  came  back  again  ;  and  the 
provisional  order  for  tracheotomy  Avas  carried  out.  Then  the 
relief  was  immediate;  the  lividity  of  countenance  vanished:  she 
shortly  fell  asleep,  and  went  on  afterwards  respiring  through  the 
tube  till  such  time  as  the  swelling  of  the  glottis  subsided  enough 
for  her  to  breathe  in  the  natural  way ;  on  which  the  instrument 
was  taken  out. 

Tracheotomy  is  an  alarming  operation  to  hear  of  or  to  look 
at,  but  in  reality  it  is  not  a  dangerous  one.  Ignorant  suicides 
often  open  the  windpipe  by  cutting  their  throats  right  in  front ; 
yet  they  fail  to  kill  themselves,  if  they  miss  the  great  vessels. 
And  if  a  wound  under  circumstances  of  such  violence  does  not 

*  Few  wrong  renderings  have  done  so  much  harm  as  this,  wliich  has  led 
people  to  intrench  themselves  under  the  authority  of  the  shrewd  Greek,  when 
they  increase  the  violence  of  their  remedies  in  proportion  to  the  violence  of  dis- 
ease. I  have  heard  M.  Chomel  do  so  when  bleeding  the  most  severely  the  worst 
cases  of  Pneumonia;  and  "  the  more  syphilis  the  more  mercury  "  was  the  rule 
acted  upon  at  the  Lock  hospital  not  many  years  ago. 


ACUTE  LARYNGITIS.  225 

kill,  liow  is  it  likely  to  do  so  when  made  with  the  deliberate 
caution  of  a  surgeon?  In  point  of  fact  I  cannot  find  on 
record  an  instance  of  its  being  fatal.  Patients  often  die  after 
it,  because  laryngitis  is  so  often  complicated  with  extensive 
pneumonia,  croup,  diphtheritis  ;  hut  I  cannot  find  anything  to 
show  that  tracheotomy  has  ever  hastened  the  death ;  nay — in 
most  even  of  these  it  seems  to  have  postponed  the  unfortunate 
termination.  Do  not,  therefore,  alarm  the  patient's  friends  by 
speaking  of  it  as  "a  last  hope,"  "a  final  resource,"  or  by  any 
similar  weak  expression.  Doubtless  there  is  danger  in  the  ope- 
ration— the  danger  of  hemorrhage  into  the  trachea ;  but  there 
is  not  half  the  danger  your  patient's  friends  are  sure  to  antici- 
pate, and  are  ready  to  exaggerate,  if  encouraged  by  your  giving 
way  to  weak  fears.  The  consequence  of  this  conduct  on  your 
part  is  that  they  beg  you  to  postpone  it  a  little  and  a  little  longer, 
till  the  time  has  passed  for  a  chance  of  success.  Each  minute 
the  throat  is  becoming  more  swollen  and  filled  with  black  blood, 
and  there  is  more  likelihood  of  the  surgeon's  hand  being  stayed 
by  troublesome  hemorrhage  ;  and  hemorrhage  is  the  only  thing 
at  all  to  be  feared  in  the  performance  of  the  operation.  Each 
minute  congestive  pneumonia  is  becoming  more  and  more  prob- 
able ;  more  and  more  incurable,  if  already  existing. 

The  only  reason  for  delay  is  that  of  which  you  saw  an  instance 
in  the  present  patient ;  namely,  a  possibility  that  the  excessive 
urgency  of  the  symptoms  may  be  due  to  some  easily  obviated 
external  cause,  such  as  cold,  weariness,  nervous  excitement,  hys- 
teria, or  the  like.  It  was  not  improbable  that  a  patient,  chilled 
with  coming  to  the  hospital  and  sitting  in  the  waiting-room, 
might  appear  worse  than  she  really  was,  and  that  warmth,  food, 
and  rest,  might  alleviate  the  pressing  danger.  They  did  so  to  a 
certain  extent;  but  not  so  far  as  to  prevent  a  relapse. 

It  is  not  my  place  to  say  much  about  the  surgical  part  of  the 
business.  I  will  merely  tell  you  what  the  physician  requires  of 
the  operator.  His  requirements  are: — 1.  That  blood  shall  not 
be  allowed  to  get  into  the  trachea  (to  secure  which  the  use  of  a 
simple  scalpel,  and  the  waiting  for  all  serious  bleeding  to  have 
ceased  before  the  cartilages  are  cut,  are  the  best  means).     2. 


226  ACUTE  LARYNGITIS. 

That  the  opening  shall  be  large  enough  to  admit  of  a  sufficient 
body  of  air  ;  that  is  to  say,  it  must  be  capable  of  being  stretched 
to  nearly  the  diameter  of  the  trachea.  3.  That  the  instrument 
inserted  should  be  capable  of  being  kept  clean  by  a  nurse,  and 
not  easily  jerked  out  by  spasmodic  movements  on  the  part  of  the 
patient.  The  ordinary  curved  double  canula  seems  to  me  the 
best. 

So  far  for  restoring  the  deficiencies  of  the  respiratory  func- 
tions. 

But  other  functions  call  for  care  also.  You  Avill  have  seen  in 
the  case-book  that  half  a  pint  of  warm  beef-tea  was  ordered  to 
be  thrown  up  into  the  colon  by  enema  every  three  hours  from 
the  first  hour  of  admission.  These  patients  are  usually  suffering 
as  much  from  "want  of  food  as  from  want  of  air.  The  deficiency 
does  not  kill  them  so  rapidly  as  the  impediment  to  respiration; 
nor  does  it  make  itself  so  conspicuous;  and  for  that  very  reason 
is  apt  to  be  forgotten.  But  observe  the  convulsive  motions  of  a 
patient  with  laryngitis  on  trying  to  swallow,  and  you  will  not  be 
surprised  that  they  resist  all  attempts  at  feeding  by  the  mouth, 
and  that  nurses  have  no  heart  to  force  them.  The  attempt  is 
another  name  for  strangulation.  Yet  if  they  get  no  nourishment, 
they  are  hourly  becoming  less  able  to  bear  up  against  the  de- 
pressing influence  of  the  devitalised  blood,  less  able  to  renew  the 
injured  larynx.  This  is  a  matter  of  great  moment,  not  only  as 
regards  the  present  retention  of  life,  but  as  regards  the  latter 
prospects  of  the  patient.  For  the  last  hundred  years  people 
have  been  writing  a  great  deal,  more  or  less  wisely,  about  laryn- 
gitis; but  I  do  not  think  any  one  has  noticed  this  important 
part  of  the  treatment  since  Van  Swieten  a  hundred  years  ago. 
("  Commentary  on  Boerhaave,"  vol.  viii,  sect.  813,  ad  fin.)  It 
seems  not  improbable,  from  the  details  given  in  published  cases, 
that  nuniy  of  those  whose  immediate  danger  has  been  happily 
postponed  by  the  operation,  have  died  of  starvation  through  the 
neglect  of  this  simple  measure. 

Whenever  you  want  to  administer  nutriment  in  enema,  it  is 
well  to  prevent  it  from  running  off  before  being  absorbed  by 
adding  a  few  drops  of  an  opiate.     This  was  done  at  first  in  our 


ACUTE  LARYNGITIS.  227 

patient's  case;  but  it  was  not  necessary  to  continue  it,  as  no 
fjeces  were  passed  per  anum  for  three  days. 

When  the  powers  of  life  have  been  so  reduced  by  the  de- 
ficiency of  the  respiration  that  the  mucous  membrane  of  the 
intestinal  canal  rejects  the  food  undigested,  you  may  mix  pep- 
sine  with  it ;  and  you  may  appropriately  administer  tincture  of 
bark  and  port  wine.  Both  were  ordered  on  this  girl's  card; 
but  little  of  either  was  given,  since  within  forty-eight  hours 
after  the  operation,  her  pulse  had  got  full  and  natural.  Always 
remember  Avhat  I  told  you  when  lecturing  on  low  fever — wine  is 
an  adjunct  or  help  to  restorative  treatment,  but  if  made  to  take 
its  place,  is  hurtful. 

When  the  patients  begin  to  take  food  again  by  the  mouth, 
you  will  often  find  that  solids  of  certain  kinds  are  easier  swal- 
lowed than  pure  liquids.  This  is  noticeable  in  all  kinds  of 
dysphagia;  in  fact,  the  embracing  of  a  gulp  of  fluid  by  the 
semi- voluntary  pharyngeal  muscles  is  a  greater  effort,  and  more 
apt  to  cause  spasm,  than  happens  with  a  more  resisting  mass. 
You  can  try  this  any  day  in  your  own  throats.  You  must  there- 
fore choose  as  the  solid  you  administer  to  the  patient  some  one 
which  slips  down  easily,  such  as  the  oysters  which  have  been 
ordered  for  this  girl. 

I  feel  you  expect  me  to  say  something  about  two  medicines 
which  have  been  recommended  in  acute  laryngitis — antimony 
and  mercury.  I  must  confess  I  have  never  been  able  to  trace 
any  advantage  from  their  use,  either  in  cases  of  recovery,  or  of 
death.  I  no  longer  use  them,  and  do  not  recommend  them  to 
you.  The  action  of  the  salts  of  these  metals  is  to  increase  de- 
structive metamorphosis,  and  to  lower  the  force  of  the  heart. 
By  such  means  they  certainly  do  appear  to  me  to  have  a  con- 
trolling power  over  inflammation.  But  it  is  a  power  exercised 
slowly,  and  at  the  expense  of  depressing  the  general  vitality 
rapidly ;  so  that  they  are  peculiarly  unsuitable  for  cases  where 
an  effect  is  desired  to  be  quickly  produced;  for,  if  enough  of 
them  is  given  to  stop  inflammatory  action  in  the  short  time 
allowed  us,  a  serious  lowering  of  the  vitality  follows,  extremely 
dangerous  in  its  most  remote  consequences  to  the  patients  who 
have  already  had  to  bear  the  shock  of  being  half  stifled. 


228  ACUTE  LARYNGITIS. 

What  I  would  have  you  mainly  keep  in  mind,  in  your  treat- 
ment of  laryngitis  is  as  follows: 

1.  If  the  external  and  obvious  conditions  of  the  patient  be 
such  that  some  part  of  the  symptoms  may  be  due  to  those  con- 
ditions, remove  them.  Warm  the  surface  of  the  body;  saturate 
with  hot  steam  the  air  inspired ;  put  on  leeches,  and  hot  fomen- 
tation to  the  throat.     In  special  favorable  cases,  bleed. 

2.  If  benefit  do  not  quickly  follow,  perform  tracheotomy,  or 
get  it  performed. 

3.  If  a  relapse  occur  after  temporary  benefit,  every  minute 
that  the  operation  is  delayed  is  an  opportunity  lost. 

4.  Food  must  be  sedulously  administered,  if  not  by  mouth, 
then  by  rectum.  This  is  especially  needful  if  leeches  are  put  on, 
more  especially  if  you  decide  to  bleed,  and  still  more  especially 
than  ever  if  mercury  or  antimony  have  been  thrown  in  by  your- 
self or  others. 

5.  Let  the  restored  air  for  respiration  be  moist  and  warm ; 
and  take  care  that  there  is  enough  of  it,  by  inserting  a  full-sized 
double  canula  in  the  trachea,  and  heedfully  watching  the  orifice 
day  and  night,  lest  it  get  blocked  up  by  mucus. 

As  a  contrast  to  the  disease  in  the  larynx  inducing  such 
serious  danger  by  its  locality,  but  rapidly  recovered  from  by 
reason  of  the  slight  morbid  alteration  which  has  taken  place,  I 
show  you  here  a  larynx  taken  this  week  from  the  body  of  a  man 
who  died  of  pulmonary  consumption.  See  how  extensively  it  is 
disorganized.  The  mucous  membrane  covering  all  the  upper 
part  is  white,  thick,  and  rough  ;  just  below  the  vocal  cords  on 
the  right  side  there  is  a  ragged  deep  ulcer,  which  has  bared  the 
arytenoid  cartilages,  and  caused  them  to  become  necrosed  by 
killing  the  pericondrium  ;  a  piece  of  the  dead  cartilage  projects 
into  the  bottom  of  the  cavity.  There  is  another  superficial  ulcer 
in  a  corresponding  place  on  the  opposite  side.  Yet  here  the 
symptoms  referable  to  the  larynx  were  of  very  little  weight.  The 
man's  voice  was  indeed  hoarse  and  weak,  but  not  more  so  than 
you  find  in  most  sufferers  dying  with  a  very  large  vomica  in  one 
lung  and  the  other  filled  with  crude  tubercles,  as  we  found  in 
this  autopsy.     There  was  a  considerable  secretion  of  pus  also, 


ACUTE  LARYNGITIS.  229 

and  pain  in  the  larynx  when  pressed,  but  there  was  no  difficulty 
of  breathing,  in  whatever  position  the  patient  lay.  Consequently 
no  local  applications  were  made  to  the  organ.  There  was  no 
demand  for  local  interference,  and  certainly  it  would  have  been 
useless  for  the  lengthening  of  life.  The  need  calling  for  restora- 
tive treatment  was  the  weighty  one  of  chronically  deficient 
nutriment  to  the  whole  system.  The  larynx  was  ulcerated  and 
degenerated  for  the  same  reason  that  the  kidneys  were  shrunken 
and  granular,  and  that  the  whole  person  was  worn  down  to  a 
skeleton — sufficient  aliment  was  not  absorbed  to  compensate 
waste.  A  despairing  effort  indeed  we  made  to  supply  this  by 
trying  to  restore  digestive  and  absorbent  powers  to  the  alimentary 
canal  with  quinine  and  iron,  and  to  feed  muscle  and  fat  with  meat 
and  cod-oil.  But  in  vain.  Sentence  of  death  had  long  before 
gone  forth  ;  and  it  was  hard  to  say  that  the  decree  was  in  any 
measure  stayed  by  treatment,  however  suitable  it  may  have 
been. 

My  object  in  quoting  this  case  now  is  not  by  it  to  praise  the 
remedial  agents  brought  into  play,  but  to  draw  your  attention 
to  the  rule,  that — the  immediate  danger  of  diseases  is  mainly 
traceable  to  their  locality,  the  final  danger  to  the  extent  and 
intensity  of  the  pathological  changes.  I  would  lay  it  down  as 
a  law  to  be  observed,  that  in  cases  where  the  danger  is  imminent, 
the  attention  of  the  medical  attendant  should  be  directed  to 
locally  active  remedies;  where  the  risk  is  more  remote,  his  mind 
should  be  turned  to  those  of  general  agency.  Thus  in.  acute 
laryngitis  you  are  to  think  of  the  larynx  alone,  to  the  temporary 
neglect  of  other  parts ;  in  chronic  laryjigitis,  you  are  to  consider 
the  general  nutrition  in  preference  to  the  local  injury. 


LECTURE   XIX. 
CAPILLARY   (OR  SUFFOCATIVE)    CATARRH. 

Definition  of  the  disease — The  mildness  and  severity  deiieiid  on 
the  quantity  of  bronchial  membrane  involved — Slighter  cases 
essentially  of  the  sajne  nature  as  the  severe  cases  here  brought 
forward. 

First  Case. —  Uncomplicated  bronchial  catarrh. 

Second  Case. — The  same  arrested  on  the  brink  of  merging  in 
hronclio-pneumonia — Treatment  by  warmth  and  moisture — 
The  same  treatment  [kludge's)  applicable  to  mild  cases — 
Bloodletting . 

Third  Case. — Bronchial  catarrh  fatal  by  supervening  on  lung 
previously  impeifect — Autopsy — Such  form  of  fatal  disease 
aptly  described  as  paralysis  of  the  lung — Equally  fatal  to 
strong  as  to  puny  peop>le — Arises  from  exposure  to  cold  air 
during  a  catarrh — Danger  much  increased  by  imperfection  of 
lung. 

[Clinical,  St.  Mary's,  January  23,  1864.) 

The  late  weather,  frosty,  dry,  and  dusty,  has  borne  its  usual 
crop  of  severe  bronchial  catarrhs.  Three  of  these  came  under 
my  care  last  week,  and  I  shall  take  the  opportunity  of  making 
a  few  remarks  upon  the  nature  of  the  disease  and  the  treatment 
required  by  the  patient. 

What  you  see  before  you  is  a  disease  consisting  of  a  rapidly 
occurring  congestion  of  the  mucous  membrane  of  large  and  small 
air-passages,  resulting  in  the  pouring  out  of  mucus  and  pus,  and 
tending  to  destroy  life  by  dyspnoea. 

In  its  slighter  forms,  and  when  affecting  the  trachea  princi- 
pally, it   constitutes  the  well-known   "cold  on  the  chest"  or 


CAPILLARY  CATARRH.  231 

"bronchitis"*  of  the  public  in  general.  And  when  it  is  preva- 
lent on  an  epidemic  scale,  it  is  called  "influenza."  In  these 
cases  it  appears  to  affect  almost  entirely  the  trachea  and  larger 
air-passages,  and  the  oxidization  of  the  blood  is  hardly  at  all 
interfered  with.  When  the  smaller  or  capillary  bronchi  suffer, 
then  a  serious  interference  with  the  aeration  takes  place,  and 
the  catarrh  becomes,  what  is  well  called  in  old  writers,  "suffo- 
cative," or  in  more  anatomical  phraseology,  "capillary  catarrh." 

These  cases  differ  from  other  bronchial  catarrhs  in  the  extreme 
sense  of  suffocation  or  dyspnoea,  quite  out  of  proportion  to  the 
physical  signs  elicited  by  auscultation,  or  to  the  cough  and 
amount  of  expectoration. 

Important  as  the  slighter  cases  are  on  the  score  of  frequency, 
I  cannot  find  suitable  examples  for  clinical  lecturing,  for  they 
usually  are  so  much  better  after  the  seventh  day,  if  there  is  no 
other  disease  in  the  chest,  that  they  seldom  appear  in  the  wards. 
I  can,  however,  exemplify  by  the  more  severe  cases  the  treat- 
ment; the  principles  of  which,  and  most  of  the  details  of  which, 
are  applicable  equally  to  all. 

The  first  patient  to  which  I  ask  your  attention  is  Ellen  C,  a 
married  Avoraan,  aged  twenty-two,  eight  months  pregnant  with 
her  second  child,  who  was  admitted  on  the  8th  instant,  during 
the  frost.  She  is  robust  and  sturdy,  and  has  not  suffered  any 
inconvenience  from  her  pregnancy  She  had  a  cough  for  a  fort- 
night, but  it  gave  her  so  little  inconvenience  that  she  had  not 
laid  up  till  New-year's  day,  when  it  got  much  worse,  and  was 
accompanied  by  such  shortness  of  breath  that  she  was  obliged 
to  keep  her  bed,  and  w^as  conveyed  from  thence  to  the  hospital. 
You  see  that  the  dyspnoea  was  excessive,  her  face  was  congested 
and  the  lips  livid,  and  she  brought  up  by  frequent  coughing  a 
small  quantity  of  tenacious  sputa,  partly  frothy  with  large  bub- 
bles, Jind  partly  consisting  of  small,  round  lumps  of  tough  mucus. 

*  This  word  is  vaguely  applied,  both  by  patients  and  by  the  profession  when 
talking  to  patients,  to  any  cough  with  expectoration.  I  believe  peojile  Hive  much 
better  to  hear  tliat  they  have  "bronchitis,"  than  to  hear  that  they  are  coughing 
and  spitting;  but  I  think  among  ourselves  we  ought  to  give  up  the  term  as  the 
name  of  a  definite  ailment;  for  it  has  been  so  much  misused  that  it  is  too  late  to 
make  it  scientifically  distinctive. 


232  CAPILLARY  CATARRH. 

The  pulse  was  120.  Auscultation  of  the  chest  showed  the  lungs 
resonant,  but  filled  with  whistling,  cooing,  and  all  kinds  of  dry 
rales  throughout,  so  loud,  that  the  few  moist  sounds  were  seldom 
audible.     She  appeared  in  imminent  danger. 

The  whole  chest  was  immediately  enveloped  in  a  jacket  poul- 
tice of  linseed  meal,  and  she  was  directed  to  breathe  entirely 
through  a  Mudge's  inhaler,  kept  supplied  with  hot  water. 

On  the  next  day,  the  9th,  the  dyspnoea  was  much  relieved, 
and  the  pulse  had  sunk  to  100.  The  same  treatment  was  per- 
sisted in. 

On  the  13th  the  pulse  was  88,  and  she  left  off  the  inhalation ; 
on  the  16th  it  was  72 ;  the  sputa  were  more  opaque,  and  she 
breathed  easily.  The  poultice  was  then  discontinued,  and  a 
blister  was  applied  to  the  chest.  An  ounce  of  decoction  of  bark 
was  also  ordered  to  be  taken  three  times  a  day. 

This  is  a  case  of  generally  diffused  acute  bronchial  catarrh 
without  tendency  to  pneumonic  condensation. 

The  second  case  is  that  of  Edward  C,  aged  twenty-four,  a 
bricklayer,  now  in  Albert  ward.  He  said  he  had  been  first 
seized  by  a  cough  and  pain  across  the  front  of  the  chest  on 
Christmas  eve.  This  took  him  off  Work  immediately,  but  his 
breath  did  not  get  short,  as  it  was  when  we  first  saw  him,  till  a 
fortnight  had  elapsed,  and  the  frost  had  commenced.  Before 
admission  he  had  been  attending  a  few  times  as  an  out-patient, 
and  it  was  on  the  last  occasion  of  his  so  attending,  viz.,  on  the 
13th  instant,  that  Dr.  Markham  sent  him  up  stairs  to  bed,  as 
too  ill  to  be  allowed  to  leave  our  doors.  The  dyspnoea  and 
lividity  of  face  were  not  so  great  as  in  the  last  patient,  but  there 
was  the  same  general  diffusion  of  sibilant  rales  without  dullness 
on  percussion  marked  in  any  region.  I  say  the  dullness  was  not 
marked  in  any  part;  but  after  examination  by  the  stethoscope 
had  shown  some  fine  crepitation  beneath  the  right  clavicle  I 
percussed  again,  and  then  some  of  the  bystanders  thought  that 
the  upper  lobe  was  not  quite  so  resonant  as  the  other.  The 
tongue  was  white  and  furred,  the  sputa  copious  and  frothy,  and 
reported  to  have  sometimes  a  yellow  stain. 


CAPILLARY  CATARRH.  233 

He  wanted  to  go  home  to  fetch  "his  things,"  but  his  request 
was  not  complied  with.  He  was  ordered  to  be  put  to  bed 
immediately,  and  to  be  cupped  to  the  extent  of  six  ounces 
beneath  the  right  clavicle,  the  chest  to  be  enveloped  in  a  jacket 
poultice,  and  the  vapor  of  hot  water  to  be  inhaled. 

On  the  16th  there  was  no  fine  crepitation  or  dullness  on  per- 
cussion. On  the  20th  the  sputa  had  become  purulent,  and  the 
cough  alleviated  during  the  day,  though  troublesome  at  night. 
He  was  then  ordered  two  grains  of  quinine  thrice  a  day,  and  to 
leave  off  the  poultice,  and  has  continued  to  convalesce. 

This  is  a  case  of  acute  bronchial  catarrh  arrested  just  on  the 
verge  of  resulting  in  bronchial  or  catarrhal  pneumonia. 


You  may  observe  that  the  treatment  of  both  these  cases  has 
been  essentially  the  same  as  regards  the  most  seriously  injured 
part,  the  bronchial  mucous  membrane.  Moist  warmth  has  been 
kept  continuously  applied  to  both  the  inside  and  the  outside  of 
the  chest.  Moist  warmth  is  the  most  powerful  restorer  of 
arrested  circulation  and  vital  action  that  we  possess,  the  safest 
therapeutical  engine  we  know  of,  because  the  most  direct 
renewer  of  life. 

Perhaps  you  may  exclaim  that  this  mode  of  inhalation  limits 
the  supply  of  oxygen,  which  is  so  much  needed  for  the  aeration 
of  the  blood.  I  frankly  grant  that  there  is  less  free  oxygen  in 
warm  steam  than  in  cold  air,  and  that  therefore  certainly  less 
oxygen  goes  into  the  trachea;  but  I  am  not  sure  that  less  oxygen 
is  absorbed  by  the  pulmonary  membrane.  For  this  dilution  with 
warm  steam  softens  the  tissue,  and  makes  it  more  apt  for  endos- 
mose;  and  even  in  its  immediate  action  it  may  cause  more 
oxygen  to  be  digested  (if  I  may  so  say)  from  the  weak,  than 
from  the  strong  supply. 

But  oxygen  (as  I  have  often  pointed  out  to  you)  is  exceed- 
ingly injurious  to  tissues  in  the  state  of  partial  death  which  we 
call  inflammation,  and  therefore  the  limiting  its  supply,  to  such 
extent  as  is  consistent  with  safety,  is  not  a  thing  to  be  avoided. 

You  may  ask  whether  this  mode  of  treatment  be  applicable  to 


234  CAPILLARY  CATARRH. 

the  milder  cases,  such  as  you  will  have  more  to  do  with  in  privats 
practice  than  in  a  hospital.  Yes — there  is  nothing  like  the  in- 
haler for  a  cold  on  the  chest,  for  which,  indeed,  it  Avas  first  in- 
troduced by  Mudge.*  But  you  will  not  persuade  persons  with 
a  will  of  their  own  to  submit  to  a  jacket  poultice,  unless  thej 
are  nearly  as  ill  as  our  present  patients. 

If  there  is  much  thirst,  effervescing  draughts  of  citrate  of  am- 
monia seem  to  be  liked ;  but  when  the  illness  is  a  serious  one 
there  is  some  danger  in  advising  treatment  by  drugs,  because 
sick  persons  are  so  prejudiced  by  habit  in  its  favor,  and  it  is 
so  convenient  to  them,  that  there  is  a  risk  of  their  neglecting  the 
other  and  more  important  parts  of  the  advice. 

As  soon  as  the  mucus  became  opaque,  you  will  observe  that 
I  ordered  quinine.  Begin  your  tonics  always  as  soon  as  you 
can,  for  they  enable  more  food  to  be  digested,  and  thus  they 
shorten  the  convalescence. 

In  the  second  case,  bloodletting  by  cupping  glasses  was 
ordered  beneath  the  right  clavicle.  This  was  done,  because 
pneumonia  seemed  to  be  just  commencing  in  the  upper  lobe  of 
the  lung — a  very  dangerous  situation  for  it  to  commence  in, 
much  more  dangerous  than  in  the  lower  lobe,  and  demanding 
prompt  measures  as  much  as  the  more  generally  diffused  bron- 
chial affection. 


The  third  case  I  shall  commence  by  the  post-mortem  dissec- 
tion. On  Wednesday  some  of  you  saw  the  examination  of  the 
body  of  a  woman  aged  about  forty,  externally  in  good  condition 
and  not  emaciated  or  presenting  any  aspect  of  chronic  ailment. 
The  removal  of  the  ribs  disclosed  the  right  lung  contracted  very 
much,  and  clothed  as  to  its  lower  part  with  a  smooth  white 
leathery  coat,  not  adherent  to  the  walls  of  the  chest,  and  but 
slightly  to  the  lung,  though  it  had  bound  the  lobe  together  in 
its  contraction,  and  had  caused  atrophic  degeneration  of  its 
tissue.     It  was  probably  the  remains  of  old   hydrothorax,   for 

*  "  Radical  cure  for  a  recent  catarrhous  cough,  with  a  chapter  on  the  vis  vitte, 
&c."     Second  edition.     1779. 


CAPILLARY  CATARRH.  235 

which  she  was  in  St.  Mary's  about  three  years  ago.  The  upper 
lobe  of  the  same  lung  was  not  much  better  fitted  for  receiving 
air,  for  it  contained  old  and  contracting  chalky  tubercle,  and  a 
vomica  of  ancient  date  as  big  as  a  chestnut.  In  the  left  lung 
there  was  no  tubercle  or  consolidation  or  signs  of  pleuritic 
disease ;  but  the  whole  substance  was  doughy,  retaining  the 
marks  of  the  five  fingers  when  the  hand  was  pressed  upon  it. 
The  tissue  was  not  nearly  so  crepitant  as  it  should  be,  and  it 
was  black  with  venous  blood.  Some  parts  seemed  more  decidedly 
emphysematous.  The  trachea  and  bronchi  were  deeply  reddened 
and  dry,  no  pus  exuding,  as  it  so  often  does,  from  their  orifices 
when  cut  across.  Heart  and  abdominal  viscera  were  of  quite 
normal  appearance. 

This  woman  was  in  the  hospital  but  four  days,  and  was  too 
ill  for  us  to  learn  much  from  her  during  life.  She  was  a  quiet 
gentleman's  cook,  and,  though  habitually  subject  to  cough  and 
short-winded,  had  been  able  to  do  her  moderate  work  somehow 
till  the  arrival  of  our  late  severe  weather.  That  laid  her  up, 
and  in  a  week  reduced  her  to  the  condition  in  which  she  was 
on  admission,  namely,  hardly  able  to  breathe  even  when  propped 
up  in  bed,  with  the  face  livid,  and  the  pui'ple  blood-shot  eyes 
starting  out  of  their  sockets.  I  do  not  think  she  had  any  ex- 
pectoration. Dry  cupping  and  poultices  did  no  good,  and  she 
was  unable  to  foment  the  bronchi  with  Mudge's  inhaler.  As 
from  the  resonance  on  percussion  over  the  cardiac  region,  I  had 
suspected  there  was  a  good  deal  of  emphysema,  I  gave  her  some 
lobelia  and  ether,  but  I  could  not  perceive  that  it  brought  any 
relief. 

There  is  more  instruction  to  be  gained  from  the  appearances 
after  death.  I  dare  say  some  of  you  can  call  to  mind  that 
terrible  February  during  the  Crimean  war,  when  the  apparently 
tough  sovereign  of  our  tough  enemies  was  suddenly  death-struck, 
while  actively  engaged  in  his  patriotic  duties.  Few  can  forget 
the  ghastly  satire,  too  bitter  for  us  even  at  that  time,  with 
which  "Punch's"  artist  hailed  the  event;  and  medical  men 
remember  how  the  public  was  puzzled  by  the  bulletin  of  the 
German  physicians,  who  announced  the  death  as  due  to  "para- 


236  CAPILLARY  CATARRH. 

lysis  of  the  lungs."  By  this  unusual,  but  not  inapt  term  they 
intended  to  designate  that  complete  obliteration  of  function 
•which  we  see  in  such  lungs  as  these ;  and  the  emperor's  illness 
was  of  the  same  nature  as  I  am  quoting  three  examples  of  to- 
day, namely,  inflammation — a  partial  death — of  the  bronchial 
mucous  membrane  resulting  in  obliteration  of  function.  It 
arose  too  under  the  same  circumstances  of  exposure  to  severe 
dry  frost  during  a  catarrh. 

People  were  surprised  at  the  rapid  sinking  of  a  man  so  re- 
markably muscular  and  strong  as  our  gallant  enemy.  But  I 
happened  at  that  very  time  to  be  called  to  see  a  country  clergy- 
man of  large  frame  and  great  height,  who  sank  in  the  same  way 
from  fatal  bronchial  catarrh,  brought  on  by  exposure  during  a 
cold  on  the  chest.  So  that  I  felt  less  surprise  than  others. 
And  I  am  rather  disposed  to  think  that  big  burly  people,  once 
severely  smitten,  yield  to  the  disease  with  more  than  ordinary 
rapidity. 

I  have  noticed  in  the  second  case,  how  anxious  I  was  to  pre- 
vent the  man  from  going  out  in  the  cold  after  we  had  once  got 
him  up  into  the  ward.  My  reason  was  a  feeling  of  the  extreme 
danger  not  only  of  the  extension  of  the  catarrhal  state  which  is 
brought  about  by  cold  air,  but  also  of  the  penetration  of  the 
inflammation  to  the  tissue  of  the  lung  (lobular  or  catarrhal 
broncho-pneumonia).  Of  the  two  ways  by  which  inflammation 
penetrates  to  the  lungs,  from  the  inside  or  the  outside,  the 
former  is  much  the  worst.  I  have  no  doubt  but  what  it  was  the 
unfortunate  independence  of  control,  which  is  a  necessary  part 
of  sovereignty,  that  destroyed  the  emperor.  He  was  determined 
to  go  on  with  his  duties,  come  what  might,  and  nobody's  will  was 
strong  enough  to  say,  "We  will  not  let  you." 

Any  disease  which  has  previously  limited  the  area  of  available 
lung  increases  very  much  the  danger  of  capillary  catarrh.  In 
the  patient  who  is  my  present  text  the  atrophied  state  of  the 
lower  right  lobe,  the  ancient  tuberculosis  of  the  upper,  and  the 
possibly  prevenient  emphysema  of  parts  of  the  left  lung  took 
away  her  chances  of  renewed  life.  Had  I  been  aware  of  them 
all,  I  should  have  given  a  still  more  unfavorable  prognosis  than 
even  the  symptoms  made  me  give. 


CAPILLARY  CATARRH.  237 

I  applied  the  epithet  "possibly  prevenient"  to  the  emphyse- 
matous state  of  the  pulmonary  tissue.  I  did  this  because  the 
patient  had  given  us  during  life  some  broken  history  of  short- 
ness of  breath  affecting  her  for  a  considerable  period,  and  it 
would  be  difficult  to  say  that  this  degenerated  condition  of  the 
lung  membrane  had  not  existed  as  its  cause.  But  I  said  "pos- 
sibly," because  in  fatal  cases  of  capillary  catarrh  emphysema  is 
so  often  found,  even  in  patients  previously  healthy,  that  it  cer- 
tainly must  be  a  consequence,  and  not  the  origin,  of  the  com- 
plaint. This  is  especially  the  case  in  infants,  whose  lungs,  when 
they  die  of  bronchial  catarrh  or  of  broncho-pneumonia,  are 
almost  invariably  highly  emphysematous;  a  state  of  things  which 
their  age  and  previous  good  health  show  to  be  capable  of  very 
apid  development. 


16 


LECTURE    XX. 

PNEUMONIA. 

Three  cases  of  pneumonia — 1.  Frank  uncomplicated  double  pneu- 
monia in  a  temperate  man,  with  excessive  dyspnoea — Cured 
ivith  venesection,  jacket  poultice,  continuous  feeding  and  wine. 

2.  Pneumonia  of  upper  and  lower  lobes  of  one  lung,  very 
slight  in  the  other  lung,  in  a  broken-down  old  man — Cured 
with  cupping,  jacket  poultice,  continuous  feeding  and  wine. 

3.  Co7igestive  pneumonia  of  lower  lobe  in  typh fever — Cured 
witli  half-jacket  poultice,  cutting  beneath  scapula,  continuous 

feeding,  tvine  and  bark. 
Commentary — Pathology  of  pneu7nonia — Importance  in  propor- 
tion to  qiumtity  of  tissue  involved,  not  to  stage  of  progress — 
Hence  the  value  of  a  ready  and  quick  means  of  checking  its 
progress — Bloodletting — Action  of  it — Grcneral  and  local 
compared — III  effects  of  loss  of  blood — 3Iode  of  judging  of  the 
necessity  for  it — Compensation  for  it — Poultices — their  Action 
— Especially  adapted  for  infants — Hoiv  to  make  theyn — Alco- 
hol, when  recpiiired — Effect  of  position  in  the  pneumonia  of 
typh  fever — Bloodletting —  Purgatives  —  Blisters — Antimony 
and  mercury. 

{Clinical,  St.  Marys,  May  10,  1862.) 

There  have  been  three  patients  under  my  care  in  the  Albert 
Ward  this  week  to  whom  I  have  drawn  your  attention,  as  illus- 
trative of  the  most  common  phases  under  which  we  have  to  treat 
pneumonia  in  the  adult. 

No.  1  is  a  case  of  frank  uncomplicated  inflammation  of  the 
pulmonary  tissue. 

R.  G.,  aged  twenty-one,  a  very  steady  and  temperate  police- 


PNEUMONIA.  239 

man,  well  made,  robust,  and  never  previously  ill,  was  on  April 
12,  taken  with  severe  rigors,  followed  by  a  dull  pain  in  the 
side,  and  cough.  He  got  worse  under  treatment  from  day  to 
day,  and  on  the  18th  was  so  alarmingly  ill  that  his  friends  car- 
ried him  to  the  hospital.  I  saw  him  shortly  after  he  was  put 
to  bed,  and  certainly  felt  that  they  were  justified  in  their  alarm. 
The  respirations  were  abdominal  and  were  thirty-six  in  the  min- 
ute ;  he  struggled  and  gasped  for  breath,  his  lips  and  tongue 
were  livid ;  the  pulse  was  very  quick  and  small,  but  the  heart 
beat  strongly  in  spite  of  its  great  rapidity.  The  expectoration 
was  copious  and  glairy,  of  a  deep  tawny  color,  and  with  a  few 
small  striffi  of  blood  in  it. 

The  whole  of  the  ribs  on  the  right  side  were  motionless  du- 
ring inspiration,  while  the  movement  of  those  on  the  left  front 
was  very  visible.  In  the  upper  half  of  the  upper  right  lobe,  and 
in  the  lower  right  front,  there  was  fine  crepitation  and  compara- 
tive dullness  on  percussion.  Beneath  the  right  shoulder-blade 
the  dullness  was  more  absolute  and  there  were  coarse  rales.  Be- 
neath the  left  there  was  fine  crepitation.  It  was  obvious  that 
active  inflammation  raged  throughout  nearly  the  whole  (if  not 
quite  the  whole)  of  the  right  lung,  and  in  the  lower  lobe  of  the 
left,  and  that  it  was  most  advanced  in  the  back  part  of  the  right 
side.  At  most  a  third  of  the  pulmonary  tissue  was  in  working 
condition,  so  no  wonder  that  exaggerated  puerile  breathing  was 
heard  in  that  third,  and  the  ribs  were  heaved  in  an  extraordinary 
manner,  where  heaved  at  all. 

The  patient  was  bled  to  three-quarters  of  a  pint  from  the  arm, 
took  eight  ounces  of  port  wine  during  the  twenty-four  hours,  and 
beef-tea  every  two  hours,  and  had  his  chest  completely  enveloped 
in  a  thick  hot  linseed-meal  poultice.  He  was  ordered  also  three 
efi"ervescing  draughts  of  citrate  of  ammonia  daily. 

I  am  told  that  relief  began  immediately  after  the  venesection. 
At  all  events,  next  morning  there  was  a  great  improvement,  the 
breathing  being  much  easier,  the  patient  expressing  himself  as 
"stronger,"  and  the  sputum  being  but  slightly  tinged  with 
brown.  On  the  succeeding  day  there  was  a  further  step  gained, 
and   the  pneumonic  hue  had   disappeared  altogether  from  the 


240  PNEUMONIA. 

mucus  expectorated.  However,  in  the  parts  of  the  right  chest 
in  front  whence  I  raised  the  poultice  temporarily  for  examina- 
tion, viz.,  an  inch  beneath  the  collar-bone  and  an  inch  beneath 
the  nipple,  the  dullness  on  percussion  seemed  very  decided.  But 
I  will  not  allow  myself  the  enticing  task  of  describing  a  patient's 
daily  progress  towards  health  :  suffice  it  to  say,  that  on  the  26th, 
eight  days  after  admission,  the  effervescing  draughts  were  ex- 
changed for  decoction  of  bark,  and  that  to-day.  May  10,  he 
goes  out  well.  The  respiration  is  quite  natural,  percussion  and 
expansion  normal  in  the  upper  lobe  and  back  part  of  the  lower 
lobe  recently  inflamed;  but  there  still  remained  yesterday  some 
little  crepitation  mixed  with  the  healthy  breathing,  and  slight 
comparative  dullness  below  the  mamma.  I  dare  say  it  is  gone 
now. 

No.  2. — Hugh  J.,  aged  sixty-three,  hall-porter  at  a  charitable 
institution,  a  respectable  man,  but  not  quite  free  from  a  suspicion 
of  petty  tipling,  had  an  attack  of  pneumonia  of  the  lower  half 
of  the  left  lung  under  my  care  about  this  time  last  year,  from 
which  he  entirely  recovered  so  far  as  the  local  symptoms  were 
concerned,  but  he  has  looked  older  since.  At  the  beginning  of 
last  week,  April  28,  he  was  again  taken  ill.  I  saw  him  at  his 
home  on  the  2d  of  May,  and  sent  him  up  to  this  hospital.  On 
the  right  side  the  whole  lower  lobes  and  the  greater  part  of  the 
upper  lobe  were  consolidated.  In  the  upper  lobe,  fine  crepita- 
tions were  heard  throughout.  There  was  also  some  fine  crepi- 
tation in  the  back  part  of  the  left  lung.  His  tongue  was  thickly 
furred  and  clammy,  his  hands  tremulous,  and  his  manner  ex- 
cited. There  was  also  occasional  delirium.  The  pulse  was  large, 
short,  and  empty — such  as  is  usually  found  with  the  inelastic 
arteries  of  old  age.  He  was  cupped  that  day  to  six  ounces  on  the 
cardiac  region,  and  on  the  morrow  to  the  same  amount  beneath 
the  right  clavicle.  The  chest  was  completely  enveloped  in  a 
jacket  of  linseed  poultice.  He  was  ordered  eight  ounces  of  port 
wine,  food  every  two  hours,  and  three  efiervescing  draughts  daily 
of  carbonate  of  ammonia  and  tartaric  acid. 

May  5. — Pulse  128.  On  the  4th  there  was  considerable  di- 
arrhoea, which  ceased  on  the  following  day-break,  after  a  small 
compound  ipecacuanha  powder. 


PNEUMONIA.  241 

May  6. — Less  crepitation  in  left  upper  lobe,  but  dullness  on 
percussion,  and  coarse  mixed  with  fine  crepitation  in  right  upper 
lobe.  Sputa  have  been  for  the  last  three  days  very  abundant, 
and  of  a  deep  rusty  color. 

No  change  in  the  symptoms,  except  the  gradual  diminution  in 
quickness  of  the  pulse,  is  noticed  till  to-day  (the  10th),  when  the 
sputa  are  darker  and  more  like  prune-juice,  but  showing  signs 
of  improvement  by  having  some  specks  of  opaque  purulent  mat- 
ter in  them.  The  tongue  is  also  a  little  moist,  and  only  gets 
quite  dry  after  sleep.  He  may  be  considered  to  have  turned 
the  corner  in  his  progress  toAvards  recovery,  and  I  have  no  hesi- 
tation now  in  pronouncing  a  favorable  prognosis.  No  change 
has  been  made  in  the  treatment. 

[On  May  16  he  began  to  take  bark  and  ammonia.  On  the 
morrow  the  expectoration  is  noticed  to  consist  of  clear  mucus 
for  the  first  time  since  his  admission,  and  he  left  the  hospital  to 
return  to  his  place  on  May  30.     Case-book,  161,  p.  187.] 

No.  3. — John  L.,  aged  seventeen,  w'as  brouglit  here  from  a 
house  where  his  mother  and  sister  have  just  died  of  "typhus 
fever,"  according  to  the  account  of  an  aunt  who  came  to  see  him. 
He  was  taken  ill  on  April  20,  and  when  admitted  on  April  23, 
was  as  unfavorable  a  subject  to  look  at  as  I  ever  saw  at  that 
early  period  of  low  continued  fever.  There  was  complete  pros- 
tration and  constant  delirium,  the  tongue  was  clammy  and  tremu- 
lously protruded  with  great  difficulty  from  the  dry  lips,  the  pulse 
120  and  small,  the  skin  hot  and  dry.  The  eyes  were  bloodshot, 
and  on  the  front  of  the  body  Avere  from  thirty  to  forty  fever 
spots  of  various  hues,  some  slightly  raised  and  inclining  to  rose 
color,  some  livid,  some  completely  purpuric  and  not  changed  by 
pressure.  I  mention  these  details  because  it  is  such  cases  of 
typh-fever,  where  the  haematine  of  the  blood  is  apparently  so 
much  poisoned,  that  are  aptest  to  be  accompanied  by  inflamma- 
tion of  the  lungs.  He  was  treated  in  my  usual  way  with  hydro- 
chloric and  tepid  sponging,  and  was  going  on  as  usual  very  well 
till  May  3,  when  some  fine  crepitation  and  dullness  on  percus- 
sion were  found  in  the  lower  lobe  of  the  right  lung,  accompanied 
by  slight  cough,  but  without  expectoration.     On  the  4th  he  was 


242  PNEUMONIA. 

cupped  beneath  the  right  scapula  to  four  ounces,  a  poultice  was 
applied  over  that  part,  and  he  was  directed  to  be  kept  turned 
over  on  the  left  side.  On  the  7th  the  breath-sounds  were 
healthy  except  a  little  coarse  crackling  mixed  with  vesicular 
breathing,  such  as  is  generally  found  in  typhous  patients ;  the 
percussion  was  normal.  The  tongue  and  other  muscles  were 
scarcely,  if  at  all,  tremulous.  He  is  now  going  through  a  rapid 
convalescence  under  bark  and  wine,  and  in  a  few  days  will  doubt- 
less be  able  to  stand  on  his  legs. 

Whilst  speaking  of  this  case,  and  before  I  enter  upon  the 
treatment  of  pneumonia,  I  will  make  one  observation  to  you  on 
the  importance  of  the  diagnosis  of  the  cause  of  dullness  on  per- 
cussion in  acute  fevers.  In  this  instance  there  was  no  doubt 
about  the  prognosis  of  the  rapid  termination  of  the  congestive 
inflammation.  But  you  must  not  say  the  same  on  every  occa- 
sion of  finding  the  pulmonary  tissue  condensed  in  fever.  A  man 
will  leave  the  hospital  for  a  distant  home  in  a  few  days,  who  has 
recovered  very  slowly  from  an  attack  of  spotted  fever  rendered 
severe  by  dysenteric  diarrhoea.  He  has  had  at  the  same  time 
primary  syphilitic  sores  and  a  bubo,  and  had  been  taking  mer- 
cury ;*  so  that  his  tedious  convalescence  was  quite  accounted 
for  by  his  previous  history.  Besides  this,  during  the  time  he 
was  laid  on  his  back,  I  had  found  a  considerable  amount  of  con- 
solidation about  the  middle  of  the  right  lung,  and  at  the  apex 
crepitations.  As  at  that  time  he  was  not  well  able  to  give  an 
account  of  himself,  I  was  inclined  at  first  to  set  this  down  to 
pneumonia,  to  treat  it  as  such,  and  anticipate  its  disappearance. 
You  saw,  however,  that  this  morbid  state  remained  unaltered 
when  I  examined  him  for  his  discharge,  and  it  seemed  to  me  by 
his  tale  of  former  winter  cough  and  haemoptysis  to  be  due  to 
chronic  tubercle.  He  will  probably  become  consumptive  some 
day.  Learn  from  this  case  to  take  good  heed  before  you  hail  a 
consolidation  of  the  lung  in  fever  as  merely  congestive. 

*  I  would  remark  in  passing  that  this  man's  dysenteric  diarrhoea  (i.  e.  pain 
in  the  bowels  with  fever  and  blood-stained  stools)  came  on  very  early  in  the  ill 
ness,  namely,  on  the  third  day,  although  the  usual  tendency  of  continued  fever 
this  year  is  by  no  means  dysenteric.  He  was  under  the  influence  of  mercury  at 
the  time.  The  action  therefore  of  that  drug  is  at  least  not  preventive  of  bowel 
affection.     Is  it  curative  ? 


PNEUMONIA.  243 

Now  to  return  to  the  text  of  to-day's  lecture. 

In  pneumonia  a  most  truly  vital  organ  is  smitten  ;  and  so  far 
as  the  disease  extends,  the  destruction  is  total.  A  consolidated 
or  even  congested  piece  of  pulmonary  tissue  is  absolutely  power- 
less to  filfiU  its  duties,  and  yet  that  those  duties  should  be 
fulfilled  is  essential  to  animal  life.  It  is  easy  therefore  to  un- 
derstand that  the  gravity  of  the  pneumonia  is  in  direct  propor- 
tion to  the  quantity  of  lung  involved.  The  degree  or  form  of 
the  inflammation  or  condensation  is  of  much  less  weight,  so  far 
as  immediate  danger  is  concerned,  than  the  extent  of  tissue  over 
which  it  is  spread. 

Hence  comes  the  importance  of  having  some  ready  and  effectual 
means  at  hand  to  check  the  march  of  the  inflammation  into  fresh 
parts.  If  we  can  do  this,  we  contribute  more  certainly  to  renew 
the  patient's  life  than  if  we  regulated,  however  favorably,  the 
progress  of  it  in  already  aff'ected  places.  No  means  is  so  readily 
applied,  so  immediate  in  its  operation,  as  bloodletting.  Its 
action  has  not  to  be  waited  for,  like  that  of  medicines  in  medi- 
cinal doses,  but  begins  at  the  moment  of  application.  That  is  a 
great  point  where  time  is  so  valuable.  I  believe  also  that  it  is 
the  most  active  of  the  agents  at  our  disposal,  and  that  rightly 
used  it  is  the  saving  of  many  a  life  in  pneumonia.  But  at  the 
same  time  I  would  have  you  clearly  understand  that  "this  is 
not  a  bow  for  every  man's  drawing"  at  every  time,  that  though 
it  is  most  rapid  and  active  for  good,  it  may  be  also  most  rapid 
and  active  for  evil,  and  that  foolishly  and  thoughtlessly  used  it 
has  caused  many  a  death. 

The  good  done  l)y  bloodletting  in  pneumonia  is  mechanical. 
The  pathological  state  which  asks  its  aid  may  be  drawn  as  fol- 
lows:— by  the  temporary  death  of  a  portion  of  the  lungs  the 
blood  cannot  be  -quickly  enough  passed  onwards  through  their 
tissue;  it  can  run  freely  as  far  as  the  right  side  of  the  heart, 
but  there  it  is  stopped ;  the  throng  pressing  onward  from  behind 
makes  matters  worse,  and  thus  the  balance  between  the  venous 
and  arterial  heart  is  destroyed.  You  can  feel  the  apex  of  the 
organ  beating  strongly  against  the  ribs,  the  muscular  action 
being  excited  by  the  presence  of  an  unwonted  amount  of  venous 


244  PNEUMONIA. 

blood;  yet  the  artery  at  the  wrist  is  at  the  same  time  striking 
your  finger  with  a  weakened  force.  Take  away  some  of  the 
blood  from  the  veins,  and  the  balance  is  restored;  the  pulse 
becomes  in  technical  phrase  "freer;"  that  is  to  say,  the  heart 
being  relieved  of  the  undue  crowd  in  the  right  side,  is  not 
checked  in  its  contraction,  but  is  able  to  clench  upon  its  con- 
tents, and  supply  them  steadily  to  the  arteries. 

Judge  then  of  the  fitness  of  this  treatment  by  the  balance 
between  the  heart  and  the  arteries.  If  the  apex  of  the  former 
organ  strikes  strong,  while  the  pulse  at  the  wrist  is  oppressed, 
act  freely  and  confidently.  If,  on  the  contrary,  the  ventricles 
are  weak,  while  the  pulse  is  large  and  rapping,  be  cautious  in 
what  ycu  do,  and  if  you  draw  blood  at  all,  let  it  be  by  cupping 
the  chest. 

The  advantages  of  general  and  local  bloodletting  are  of  essen- 
tially the  same  nature,  though  the  operations  differ  somewhat  in 
degree,  and  are  diversely  applicable.  Where  the  patient,  pre- 
vious to  his  current  illness,  was  in  vigorous  health,  actively 
digesting  his  food  and  actively  renewing  his  tissues,  he  Avill  bear 
and  easily  repair  the  abstraction  of  a  good  large  quantity  of 
blood.  And  a  good  large  quantity  of  blood  is  most  conveniently 
drawn  from  the  arm.  To  get  the  full  advantage  of  the  remedy 
you  would  practice  venesection.  But  if  the  pneumonia  has 
come  on  a  person  previously  an  invalid,  or  in  weak  health,  you 
fear  for  the  possible  bad  consequence  of  your  treatment,  and 
you  cast  about  for  some  means  of  getting  the  greatest  advantage 
out  of  the  least  loss  of  blood.  This  is  obtained  by  cupping  on 
the  region  of  the  heart.  Your  four  or  five  ounces  taken  from 
thence  in  a  delicate  invalid  seem  to  produce  as  much  correspond- 
ino;  effect  as  the  loss  of  twelve  or  fourteen  let  from  a  vigorous 
man's  arm. 

Or,  if  it  be  more  convenient,  you  may  put  on  leeches.  As  a 
rule,  however,  I  prefer  cupping,  for  you  can  easily  graduate  the 
depth  of  the  cuts  so  as  to  be  able  to  stop  them  with  ease :  whereas, 
leech-bites  will  sometimes  go  on  oozing  for  a  long  time  unper- 
ceived  into  the  poultice,  which  (as  I  will  instruct  you  presently) 
is  to  be  put  round  the  chest. 


PNEUMONIA.  245 

Another  advantage  of  local  bloodletting  is  the  relief  it  gives 
to  pleurisy.  There  are  few  cases  of  pneumonia  where  there  is 
not  some  amount  of  inflammation  of  the  serous  coat  of  the  lunss 
or  ribs;  and  though  the  feeling  of  oppression  in  the  chest  over- 
tops and  deadens  the  stitch  in  the  side,  which  would  otherwise 
be  felt,  yet  there  is  no  doubt  but  that  the  pleurisy  adds  to  the 
distress,  and  the  relief  of  it  is  no  mean  matter.  Local  blood- 
letting is  for  this  purpose  more  effectual  in  proportion  to  its 
quantity  than  general. 

You  will  find  some  authors  try  to  ground  rules  about  blood- 
letting in  pneumonia  on  the  supposed  degree  of  consolidation  of 
the  pulmonary  tissue.  These  rules  are  practically  inapplicable. 
They  say  you  should  bleed  so  long  as  you  know  that  the  lung  is 
in  its  first  stage  of  condensation  {i.  e.  congestion)  as  proved  by 
fine  crepitation  and  incomplete  dullness;  and  that  you  should 
not  bleed  after  it  has  once  become  completely  consolidated  so  as 
to  admit  no  air  into  the  finer  bronchi,  a  state  declared  by  the 
sound  of  coarse  crepitation  and  complete  dullness.  Such  a  rule 
is  quite  useless  at  the  bedside,  and  will  often  prevent  your  em- 
ploying active  practice  in  cases  where  it  is  urgently  called  for. 
In  the  first  place,  in  a  majority  of  cases  fine  crepitation  is  masked 
by  the  mixture  of  coarse  crepitation,  produced  by  the  presence 
of  catarrhal  mucus  in  the  larger  bronchi,  especially  in  the  catar- 
rhal pneumonia  of  the  young.  If  you  wait  till  you  can  distinctly 
hear  fine  crackles,  you  will  wait  too  long.  Moreover,  the  dull- 
ness of  congestion  is  not  necessarily  incomplete;  as  you  may 
satisfy  yourselves  by  examining  recent  congestion  in  continued 
fever,  Avhich  is  often  very  absolute,  though  so  transitory  that  a 
mere  change  of  position  may  remove  it  in  twenty-four  hours. 
Then  again,  a  slight  collection  of  scrum  in  the  pleura  may  make 
the  loAver  lobe  dull  at  the  very  outset,  and  prevent  your  bleeding 
at  a  very  early  stage,  if  you  were  to  folloAv  the  rule  I  quoted. 
But  the  most  serious  objection  to  the  rule  is,  that  you  may  have 
all  stages  of  partial  tissue-death  going  on  at  the  same  time;  one 
lobe,  or  one  part  of  a  lobe  may  have  advanced  even  to  yellow 
hepatization,  while  another  part  is  just  beginning  to  enter  into 
red  hepatization,  that  is  to  say,  into  a  condition  which  by  general 
consent  is  most  capable  of  benefit  from  bloodletting. 


246  PNEUMONIA. 

Your  best  guide  to  the  necessity  Avill  be  the  dyspnoea.  If  your 
patient  is  inhaling  laboriously  from  twenty  to  thirty  times  a 
minute,  straining  convulsively  the  muscles  of  inspiration,  you 
may  know  that  the  congestion  is  recent  and  is  spreading  to  new 
spots;  and  you  will  act  wisely  by  endeavoring  to  stop  it.  And 
your  best  check  against  excess  will  be  the  balance  of  the  heart 
and  arteries. 

Remember  that  in  letting  blood  you  are  wielding  a  dangerous 
weapon.  While  from  a  mechanical  point  of  view  nothing  can 
equal  the  aid  it  gives,  at  the  same  time  its  more  remote  or  phy- 
siological action  is  baneful.  If  you  gain  the  inestimable  boon 
of  a  restoration  of  balance  in  the  circulation,  and  a  consequent 
relief  of  dyspnoea  and  renewal  of  life  in  the  lungs,  you  must  not 
complain  if  some  evils  attend  the  process.  The  mere  loss  of  so 
much  "liquid  flesh"  is  in  itself  an  evil,  but  a  minor  one;  of 
greater  import  is  the  increased  proportion  of  effete  fibrin  and 
water  Avhich  it  induces,  the  diminution  of  solid  haematine,  and 
the  consequently  diminished  power  to  bear  up  against  the  de- 
struction, however  temporary,  of  so  much  pulmonary  substance. 

Remember  also  now  what  I  told  you  about  bleeding  in  a 
former*  lecture  on  anaemia  and  bloodletting — be  careful  to  sup- 
ply material  in  the  place  of  that  which  you  are  taking  away.  Let 
the  patient  be  fed  with  beef-tea  or  milk  every  two  hours,  just  as 
if  he  had  typh-fever.  This  is  to  be  done  in  all  severe  cases  irre- 
spective of  other  treatment;  but  I  mention  it  next  to  the  bleed- 
ing, to  remind  you  of  the  close  connection  which  there  is  between 
the  two,  between  exhaustion  and  supply.  It  contributes  as  much 
to  your  success,  whether  you  elect  to  bleed,  or  whether  you  do 
not. 

I  come  next  to  another  direct  restorative  about  the  use  of 
which  also  anywhen  and  anywhere  you  need  have  no  manner  of 
hesitation.  You  can  always,  without  any  exception  of  age,  sex, 
condition,  cause,  or  complication,  follow  a  treatment  to  which  I 
attribute  more  power  of  saving  the  lives  of  pneumonic  patients 
than  to  any  other,  and  which  you  see  me  apply  in  all  cases; — I 
mean  the  wrapping  up  the  chest  in  a  large  bath-like  poultice. 

*  ''Former"  in  respect  of  time  of  delivery.     It  comes  later  in  this  volume. 


PNEUMONIA.  247 

The  action  of  warmth  and  moisture  on  animal  tissues  tends 
directly  to  increase  their  vitality.  You  may  see  with  the  naked 
eye  a  healthy  surface  of  skin  under  their  application  renew  its 
life;  it  empties  itself  quicker  of  its  pale,  livid,  venous  blood,  and 
glows  with  a  fresh  access  of  the  bright  arterial  stream ;  it  swells 
up  elastically  with  fresh  juices;  it  is  more  delicately  sensitive 
when  used  for  the  purposes  of  touch ;  at  the  same  time  it  feels 
no  pain,  but  on  the  contrary  an  exquisitely  pleasurable  calm. 
You  cannot  see  with  your  eyes  this  renewal  of  life  in  internal 
organs,  but  you  may  infer  that  what  takes  place  in  one  tissue 
takes  place  also  in  another,  with  modifications  of  course  depen- 
dent on  distance  and  other  difficulties  of  application.  And  you 
may  infer  it  also  in  pneumonia  from  the  results;  for  you  find  the 
dyspnoea  diminished,  the  breath  being  easily  drawn  in  spite  of 
the  weight  of  the  poultice;  the  hot  fevered  skin  becomes  moist 
and  active,  and  soon  the  ribs  begin  to  move  again,  and  air  is  re- 
admitted into  the  hitherto  paralyzed  lung-tissue.  These  eflFects 
are  the  most  strikingly  shown  in  the  case  of  infants,  whose  thin- 
chested  walls  are  rapidly  and  efficiently  penetrated  by  the  influ- 
ences of  the  poultice,  and  in  whom  also  this  remedy  is  the  only 
one  really  safe  and  invariably  necessary;  for  they  cannot  afford 
much  loss  of  blood.  I  cannot  speak  too  strongly  of  the  import- 
ance of  your  adopting  it,  and  letting  all  other  treatment  be 
passed  over  rather  than  this. 

The  poultice  is  best  made  of  linseed  meal,  because  that  keeps 
moist  the  longest.  It  should  be  spread  half  an  inch  thick  on  a 
cloth  or  flannel  as  broad  as  the  circumference  of  the  thorax.  If 
any  portion  of  the  upper  lobes  be  inflamed  it  is  essential,  and 
even  if  one  of  the  lower  lobes  are  inflamed  it  is  prudent,  that  the 
poultice  should  be  deep  enough  to  cover  the  whole  chest  from 
the  collar-bones  to  the  hypochondria.  Lay  the  patient  in  it  on 
his  back,  and  fold  it  across  the  front  till  it  meets.  In  adults  it 
will  usually  keep  in  place  of  its  own  accord;  but  in  children  you 
should  have  a  tape  stitched  on  in  front  and  a  tape  behind  which 
you  can  tie  over  each  shoulder  in  the  manner  of  a  shoulder- 
strap  ;  otherwise  the  little  prisoners  wriggle  out  of  their  soft 
breastplates.     When  once  you  have  got  this  jacket  poultice  m 


24S  PNEUMONIA. 

situ,  keep  it  there,  and  desire  the  nurse,  on  pain  of  dismissal, 
never  to  take  it  off  till  another  hot  one  is  ready  to  go  on. 

In  low  fever  the  continuous  poultice  somewhat  stands  in  the 
way  of  the  cool  sponging.  But  in  practice  this  last  part  of  the 
treatment  of  fever  becomes /less  necessary  at  the  period  -whien 
congestion  and  pneumonia  occur ;  the  skin  has  then  become 
cooler  and  more  active.  Besides,  the  poultice  often  takes  the 
place  of  sponging  by  softening  and  suffusing  with  a  gentle 
perspiration  the  whole  body.  I  have  often  heard  pneumonic 
patients  complain  of  the  amount  to  which  the  moist  warmth 
makes  them  sweat. 

Alcohol,  especially  in  the  form  of  port  wine,  is  very  useful  in 
treating  pneumonia.  Even  to  hearty  temperate  persons,  when 
you  are  going  to  bleed,  it  is  desirable  to  give  a  little,  as  was  done 
in  Case  1.  A  glass  of  hot  negus  before  the  operation,  makes  it 
safer.  And  whenever  you  observe  the  nervous  system  becoming 
prostrate  by  the  extent  of  the  disease,  as  indicated  by  tremor  of 
the  hands,  quivering  of  the  tongue,  delirium,  or  dry  tongue, 
throw  in  a  little  wine  from  time  to  time.  Check  these  symp- 
toms on  their  first  threatening,  and  do  not  wait  for  the  tremor 
to  be  excessive,  the  delirium  complete,  or  the  tongue  brown  as 
well  as  dry,  or  you  may  be  too  late.  Old  persons,  especially  in 
the  upper  classes,  who  have  been  used  to  good  living,  and  per- 
sons of  all  ages  who  have  indulged  freely  in  alcoholic  liquids 
(as  Case  2),  may  begin  wine  immediately ;  you  need  not  wait 
for  the  symptoms  above  described.  Children,  on  the  other  hand, 
get  well  quicker  without  it. 

In  the  administration  of  alcohol  under  any  form,  a  rule  di- 
xectly  opposite  to  that  which  governs  the  giving  nutritious  food 
should  be  observed.  The  quantity  considered  necessary  in  pro- 
portion to  the  previous  habits  of  the  patient,  should  be  given  in 
one,  or  at  most  two  doses  during  the  twenty-four  hours.  The 
frequent  repetition  of  small  doses  has  appeared  to  me  more 
injurious,  or  at  all  events  less  beneficial  than  the  same  quantity 
in  a  few  larger  doses.* 

In  the  pneumonia  of  low  fever  position  is  of  great  importance. 

*  For  reasons  see  Lecture  XLIX.     "  On  the  use  of  alcohol." 


PNEUMONIA.  249 

So  Ion  Of  as  the  walls  of  blood-vessels  retain  their  natural  clasti- 
city,  they  are  able  to  bear  up  against  the  gravitating  force  acting 
on  the  blood  as  on  all  matter :  but  when  their  life  is  lowered  in 
disease,  the  elasticity  is  the  first  vital  property  that  suifers,  and 
the  blood  then  is  drawn  down  towards  the  lowest  part  of  the 
viscus.  This  is  especially  the  case  in  low  fever.  Lay  the 
patient,  therefore,  on  the  side  opposite  to  that  affected  (as  was 
done  in  Case  3),  or  even  on  his  face  for  a  time,  if  both  sides 
are  affected  ;  and  thus  the  very  force  of  gravitation  which  you 
feared  as  a  foe,  becomes  a  friend,  by  withdrawing  the  conges- 
tion from  the  weaker  point. 

This  boy  was  cupped  on  the  side.  You  need  not  shrink  from 
taking  a  little  blood  in  low  fever,  where  an  important  viscus 
requires  the  operation.  A  large  portion  of  the  vital  fluid  you 
take  away  is  poisoned  and  dead  already,  and  unfit  for  the  pur- 
poses of  life,  so  that  you  are  not  robbing  the  patient  to  the  full 
extent  of  the  quantity  drawn.  You  saw  the  lad  much  more 
lively  after  his  cupping  than  before.  It  is  better  to  bleed  locally 
than  generally,  because  local  benefit  is  expected  from  it  and 
not  general,  and  the  dyspnoea  is  seldom  very  urgent  in  these 
cases. 

I  always  avoid  purgatives  in  pneumonia.  My  reason  is  because 
I  have  observed  that  patients  who  have  diarrhoea  at  the  same 
time  generally  do  very  badly.  And  if  natural  diarrhoea  does 
harm,  I  infer  that  artificial  diarrhoea  does  harm  also.  I  prefer 
to  produce  constipation  by  opiates,  where  it  does  not  already 
exist.  If  the  rectum  gets  blocked  up  with  faeces,  it  is  easy  to 
wash  it  out  with  warm  enemata. 

Blisters  have  seemed  to  me  to  do  harm  where  I  have  known 
them  to  have  been  employed  before  the  patients  came  under  ray 
care.  It  is  usually  non-medical  persons  who  put  them  on,  under 
the  general  idea  that  they  are  good  for  a  cough  with  pain  in  the 
chest. 

I  am  afraid  I  must  equally  condemn  antimony  and  mercury, 
medicines  formerly  often  administered  in  pneumonia.  When  I 
used  them  I  was  often  and  often  driven  to  leave  them  off  on 
account  of  bad  symptoms  due  to  their  agency,  and  in  prosperous 


250  PNEUMONIA. 

cases  I  always  felt  doubtful  if  the  success  could  be  fairly  traced 
to  them.  Looking  now  at  nature  by  the  light  of  the  theory  of 
cure  which  I  have  set  before  you,  this  failure  is  rationally  ex- 
plained. The  agents  named  are  pure  "destructives;"  the  dis- 
ease is  also  one  of  pure  destruction  ;  there  are  in  it  fewer  of  the 
phenomena  of  retention  than  in  any  other,  and  none  of  tTie  in- 
sertion of  a  morbid  poison  in  the  system.  The  gain  then  which 
they  can  bring  is  infinitesimal,  and  the  risk  infinite  ;  they  do  more 
harm  than  bleeding  by  their  physiological  action,  without  any  of 
the  mechanical  recommendations  of  that  remedy ;  they  merely 
abet  the  worst  effects  of  the  disease. 


LECTURE    XXI. 
PNEUMONIA. 

Record  of  six  cases  wJiich  had  occurred  during  the  recess — {1st 
Case)  Caution  about  bloodletting — {2d  Case)  Pneumonia  of 
upper  lobe  in  the  stage  of  abscess — Relapse  of  pneumonia 
during  convalescence,  fatal  to  this  patient — Post-mortem  ex- 
mnination — Remarks  on  treatment — Cause  of  second  attack 
— {2>d  Case)  Pneumonia  in  Brighfs  disease  cured — State  of 
lung  afterwards — {'ith  Case)  Pneumonia  in  measles — Catarr- 
hal pneumonia — {bth  Case)  Pneumonia  treated  ivith  opium — 
When  opium  is  desirable — Reduplicating  pulse — {Qth  Case) 
Pneumonia  in  a  pregnant  woman  treated  with  opium — Re- 
marks on  vomiting  in  pregnancy. 

Cases  in  hospital  at  the  time  of  lecture — (Jth  Case)  Early  occur- 
rence of  pneumonia  in  typh fever — {Sth  Case)  Pouble  pneu- 
monia in  a  fatal  case  of  delirium  tremens — {^th  Case)  Dou- 
ble pneumonia  slowly  progressing  from  one  lung  to  another — 
Pleurisy  also  on  one  side — Food  in  convalescence — Mode  of 
recovery  of  consolidated  lung — {\Qth  Case)  Catarrhal  p)7ieu- 
monia — Severity  of  symptoms  at  first,  and  rapid  relief — 
Treatment  by  poultices  and  local  bloodletting — [llth  Case) 
Pouble  pneumonia  in  a  man  of  drunken  habits — This  p7i£U- 
monia  also  catarrhal,  and  distinguished  by  the  severity  of 
the  early  symptoms — Treatment  with  opium,  poultices,  and 
cupping — Delirium — Wine — {V2th  Case)  Pneumonia  morien- 
tum  in  death  from  other  causes. — Recapitulation  of  comments 
on  the  eases. 

{Clinical,  St.  Marys,  May  2,  1863.) 

I  HAVE  heard  complaints  made  against  clinical  lecturers,  that 
thej  do  not  sufficiently  interest  their  audience  by  presenting  for 


252  PNEUMONIA. 

consideration  strange  and  rare  cases.  1  shall  be  deeply  grieved 
if  my  exertions  cease  to  arouse  your  attention ;  but  I  must 
at  once  say  that  it  is  a  matter  of  conscience  with  me  to  set 
before  you  as  subjects  for  instruction  in  the  lecture  theater*,  and  '^ 
for  bedside  teaching,  most  commonly  those  forms  of  disease 
which  you  will  most  commonly  have  to  treat  in  after-life.  The 
time  I  shall  allot  to  each  will  be  proportioned  as  closely  as  pos- 
sible to  the  frequency  of  its  occurrence.  I  believe  that  to  be  the 
most  accurate  measure  of  its  importance  to  the  public,  and  there- 
fore to  medical  men. 

To-day  I  take  a  very  common  disease — pneumonia. 

Since  I  last  addressed  you  before  the  Easter  vacation  there 
have  been  six  cases  under  my  care  in  the  hospital,  which  are 
sufficiently  ordinary  examples  to  offer  several  points  of  practical 
instruction. 

I.  Caroline  D.,  though  a  sexagenarian,  has  never  been  seri- 
ously ill  before,  and  was  quite  well  till  the  3d  of  April,  when 
she  suddenly  lost  her  appetite  and  felt  ill  all  over.  She  had  a 
bad  cough,  but  no  local  sensation  of  pain  in  the  chest  or  else- 
where. She  was  admitted  April  10.  Her  pulse  was  104,  empty, 
sharp,  and  weak.  The  inspirations  were  thirty-six  in  a  minute. 
There  was  dullness  on  percussion  and  fine  crepitation  of  the  lower 
right  lobe,  and  some  fine  crepitation  mixed  with  healthy  breath- 
ing in  the  lower  left  lobe.  She  was  ordered — I^  Ammonia  ses- 
quicarbonatis  gr.  iv.  u3^theris  lT[xv.  Misturde  Camphorse  5J  ; 
alternd  qudque  hord.  Hirudines  xii  infra  scapulam  dextram, 
et  postea  cataplasm  da  lini  assidue  applicentur. 

The  signs  of  inflammation  did  not  further  spread,  but  the 
right  lower  lobe  became  consolidated,  so  that  on  the  18th 
bronchial  breathing  and  dullness  on  percussion  are  noted  in  that 
situation.  On  the  22d  the  pulmonary  tissue  began  to  become 
pervious  again,  and  there  was  the  well-known  "  crepitation  of 
return"  in  the  place  before  consolidated.  The  draught  was 
changed  for  a  mixture  of  squill  and  senega,  but  she  complained 
that  this  nauseated  her,  and  it  was  left  ofi",  and  no  medicines 
civen  at  all. 


PNEUMONIA.  253 

You  may  perhaps  be  surprised  that  in  treating  a  patient  so 
okl  as  three-score,  and  where  the  pulse  was  empty,  sharp,  and 
weak,  I  shouhi  have  ventured  upon  taking  blood.  But  I  had 
calculated  here  upon  receiving  valuable  aid  from  the  digestive 
organs.  Like  most  persons  who  have  lost  appetite  from  severe 
febrile  disorder,  she  had  eaten  scarcely  anything  for  several 
days.  I  calculated  therefore  that  a  continuous  animalized  diet, 
such  as  beef-tea  and  milk  every  two  hours,  would  more  than  re- 
place a  moderate  loss  of  blood,  and  I  should  have  been  sorry  to 
miss  the  advantage  which  its  local  application  confers  by  stayino-, 
as  it  does,  the  progress  of  congestion  towards  condensation  in 
the  pulmonary  tissue. 

It  is  quite  true  that  in  old  age  the  detraction  of  blood  does 
more  harm  than  in  3'outh  or  middle  age,  simply  because  there 
is  less  strength  to  spare ;  but  at  the  same  time  it  does  more  good 
than  in  youth  or  middle  age,  because  of  the  tendency  in  later 
life  which  congestions  have  to  increase,  and  to  increase  so  very 
insidiously,  and  to  recur  when  checked.  So  you  must  not  for- 
get what  a  powerful  weapon  you  are  wielding,  and  how  double 
must  be  your  caution  when  dealing  with  elderly  people. 

The  second  case  of  also  an  aged  woman,  is  practically  inter- 
esting, although  it  proved  a  fatal  one  in  the  end. 

II.  Mary  McK.,  admitted  February  27,  did  not  know  the 
date  of  her  birth,  but  looked  upwards  of  sixty.  She  had  been 
quite  well  of  late  years  till  three  weeks  previously,  when  she 
had  slept  in  a  damp  bed  after  being  exposed  to  much  heat  as  a 
washer-woman.  This  was  immediately  followed  by  rigors,  feel- 
ing of  complete  prostration,  and  loss  of  appetite.  I  fear  she  had 
but  little  care  taken  of  her  during  the  height  of  the  inflamma- 
tion, for  she  seemed  on  admission  to  be  almost  moribund,  and 
absolutely  refused  food.  On  examination  of  the  chest  the  upper 
lobe  of  the  right  lung  was  found  completely  condensed,  absolutely 
dull  on  percussion,  with  tubular  breathing  and  coarse  mucous 
rales,  and  in  some  places  coarse  bubbling.  There  was  little 
cough,  but  copious  green  expectoration. 

From  the  localization  in  the  stethoscopic  examination  of  the 
17 


254  PNEUxMONIA. 

part  affected,  it  was  very  doubtful  whether  this  were  not  a  case 
of  senile  tuberculosis.  But  the  suddenness  and  recency  of  the 
invasion  Avere  against  that  diagnosis,  and  I  inclined  to  think  it 
the  third  stage  of  inflammation  of  the  upper  lobe. 

The  diagnosis  made  but  little  difference  in  the  treatment;  for 
I  gave  her  quinine  and  cod-liver  oil  much  as  I  should  have  done 
had  it  been  determined  to  be  tubercular  phthisis. 

We  had  great  difficulty  about  the  patient's  food ;  she  said,  on 
admission,  she  could  eat  notliing,  and  at  first  she  persisted  in 
eating  nothing  voluntarily,  the  nurse  having  to  use  actual  force 
in  giving  her  the  beef-tea  and  milk  which  I  had  insisted  upon 
her  swallowing.     She  improved  considerably  under  this  treat- 
ment by  three  weeks  after  admission.     On  the  l^th  of  March  I 
found  there  was  not  the  same  extent  of  dullness  below  the  right 
collar-bone,  but  there  was  still  very  considerable  dullness  and 
very  coarse  low-toned  bubbling  rales.     She  was  recovering  also 
her  flesh  and  strength,  and  was  capable  of  being  entrusted  so 
far  Avith  her  diet  that  she  was  allowed  to  be  dressed  and  have 
ordinary  diet  and  porter  with  the  other  patients.     She  seems  to 
have  freely  used  her  permission  to  get  up,  and  to  have  fatigued 
herself  very  much  on  the  19th  and  20th.     On  the  morning  of 
the  21st  she  had  a  rigor,  lost  her  appetite,  became  feverish,  and 
had  severe  pain  in  the  head.     There  was  then  a  good  deal  of 
typh-fever  in  the  wards,  and  it  seemed  very  much  as  if  she  had 
caught  that  disease.      So  she  was  ordered  a  couple  of  emetics, 
continuous  food,  wine,  and  hydrochloric  acid.     But  on  the  26tli 
my  attention  was  drawn  to  her  lungs  by  the  expectoration  of 
orange-colored  sputa  in  considerable  quantity.     Her  tongue  had 
become  dry  and  brown  in  spite  of  the  wine,  and  yet  there  was 
none  of  the  nervous  symptoms  (such  as  obtuseness  of  sense,  de- 
lirium, or  tremor  of  the  muscles)  which  one  looks  for  in  cases  of 
typh-fever.     An  examination  of  the  chest  detected  the  serious 
fact  that  the  diagnosis  had  been  too  hasty,  and  that  the  symp- 
toms really  were  due  to  pneumonia.     The  whole  of  the  right 
lower  lobe  Avas  already  impervious  to  air  from  recent  consolida- 
tion, and  there  Avas  fine  crepitation  also  in  the  left  loAver  lobe. 
Half  a  dozen  leeches  were  put  on  the  latter  side,  and  a  jacket 


PNEUMONIA.  255 

poultice  over  the  whole  chest:  bark  and  wine  were  freely  given: 
but  little  hope  could  be  entertained  of  preserving  life.  She  sur- 
vived just  long  enough  for  the  expectoration  to  become  purulent, 
but  died  on  the  Gtli  of  April. 

At  the  post-mortem  examination  we  found  the  right  upper 
lobe  of  the  lungs  was  in  many  parts  consolidated  and  of  a  gray 
color,  and  of  a  fine  granular  appearance,  shading  off  in  the 
natural  red  color  in  the  parts  pervious  to  air.  There  were  in 
that  lobe  several  small  abscesses,  and  one  as  large  as  two  wal- 
nuts. The  right  lower  lobe,  and  to  a  less  extent  the  left  lower 
lobe,  were  consolidated  and  of  a  red  color,  leaving  on  the  whole 
about  six  inches  square  of  the  whole  pulmonary  tissue  permeable 
to  air.  The  ventricular  parietes  of  the  heart  were  pale  in  patches, 
and  the  mitral  valves  white  and  thickened.  The  kidneys  ex- 
hibited an  atrophied  appearance,  the  cortical  structure  being 
diminished  in  quantity  and  containing  many  small  cysts.  The 
liver  had  a  thickened  opaque  capsule  and  a  granular  (nutmeg) 
appearance  when  cut  into. 

In  this  case  are  displayed  two  pneumonias  in  one  patient. 
The  first  attack  in  the  upper  lobe  slie  had  rendered  much  more 
serious  in  its  consequences  than  it  otherwise  would  have  been 
by  starving  herself.  It  had  absolutely  condensed  the  pulmonary 
tissue,  and  was  already  running  on  to  abscess  on  her  admission. 
And  she  was  reduced  to  an  extreme  state  of  emaciation  and 
weakness.  So  that  a  condition  was  present  closely  resembling 
tubercular  consumption,  and  distinguishable  from  it  only  by  the 
history.  Yet  the  doubtful  diagnosis  gave  me  no  regret,  for  it 
made  not  the  slightest  difference  in  the  treatment  of  the  case, 
whose  prescription-card  made  some  of  you  set  it  down  as  an 
ordinary  case  of  phthisis,  though  I  had  determined  in  my  own 
mind  that  it  was  of  a  different  nature. 

I  cannot  forbear  here  leaving  for  a  few  minutes  the  considera- 
tion of  the  cases  immediately  before  us,  in  order  to  make  a  few 
remarks  which  possibly  at  some  future  time  may  cheer  your 
hearts  under  chilling  anxiety.  I  know  of  nothing  more  fearful 
than  the  feeling  that  upon  your  knowledge  or  ignorance  depends 


256  PNEUMONIA. 

the  life  of  a  fellow-man.  This  feeling  runs  through,  and  ought 
to  run  through,  your  whole  professional  career;  for  the  good  of 
vour  patients  jour  consciences  cannot  be  too  tender.  But  it  is 
necessarily  experienced  in  very  different  degrees  in  different 
cases,  and  in  the  present  age  you  will  find  your  anxiety  generally 
turns  upon  diagnosis.  The  patients  who  make  you  dream  and 
]-oll  about  in  your  bed  of  nights,  and  who  spoil  your  appetite, 
are  oftener  those  with  whom  you  cannot  find  out  what  is  the 
matter,  than  those  with  whom  you  do  not  know  what  to  do. 
Now,  it  is  often  a  great  comfort  to  reflect,  and  I  am  sure  it  is 
true,  that  where  pathological  conditions  closely  resemble  one 
another  in  the  symptoms  they  produce,  the  treatment  they  re- 
quire is  probably  exactly  the  same.  I  should  be  sorry  to  "lay 
a  flattering  unction  to  your  souls,"  but  this  is  simply  justice  to 
Yourselves.  IIow  often  is  it  impossible  to  ascertain,  without 
questions  which  it  is  impossible  to  press,  whether  certain  diseases 
are  due  to  previous  syphilitic  infection  or  not !  Fortunately  the 
same  tilings  are  curative  in  both  circumstances.  How  often  do 
we  reasonably  fear  to  alarm  a  timid  mind  by  inquiries  into  here- 
ditary tendencies  to  lunacy  or  consumption!  The  cases  are  ex- 
ceptional where  these  inquiries  are  absolutely  necessary.  And 
in  this  instance  it  made  no  difference  in  the  performance  of  my 
chief  duty,  that  of  prescribing  for  the  patient,  whether  those 
Avere  riglit  who  thought  the  consolidation  was  tubercular,  or 
those  who  thought  it  pneumonic. 

The  second  attack  of  pneumonia  happening  under  our  eyes 
in  the  hospital,  though  hid  from  notice  at  first  by  its  insidious 
manner  of  invasion,  I  cannot  but  attribute  to  the  patient  having 
got  up  and  overworked  her  weak  muscular  powers.  You  may 
all  be  aware,  from  experience,  how  even  in  healthy  persons  un- 
wonted exertion  will  cause  temporary  congestion  of  the  respi- 
ratory tract.  The  stitch  in  the  side  and  shortness  of  breath  after 
running  are  well  known.  If  we  take  violent  exercise  during 
catarrh,  the  mucus  is  often  stained  yellow  some  hours  afterwards. 
I  remember  once  having  haemoptysis  on  the  morrow  of  a  hard 
day's  skating,  though  my  lungs  are  quite  healthy.  In  an  injured 
liing  this  tendency  is  still  more  marked  and  hurtful.     Consump- 


PNEUMONIA.  -257 

tive  persons  often  spit  blood  after  unusual  exertion ;  not  as  is 
sometimes  represented,  at  the  time  of  the  exertion,  and  from  the 
strain  caused  by  it,  but  next  day,  as  a  consequence  of  the  con- 
gestion. There  was,  then,  nothing  more  likely,  than  that  this 
aged  woman  should  get  congestion  from  the  same  cause,  and 
nothing  more  likely  than  that  it  should  run  on  rapidly  to  con- 
solidation in  her  weak  state,  and  with  her  antecedent  tendency 
to  degeneration.  It  is  a  warning  to  us  to  be  more  careful  in 
watching  over  patients,  and  in  avoiding  everything  which  tends 
to  exhaust  the  failing  life. 

The  degenerative  tendencies  made  evident  by  the  state  of  the 
kidneys,  liver,  and  heart,  rendered  the  renewal  of  life  very  un- 
likely in  this  case.  But  that  is  nothing  against  doing  our  best. 
Patients  as  much  degenerated  as  that  often  go  about  for  years, 
and  with  extreme  care  may  sometimes  be  brought  round  from 
apparently  fatal  illnesses. 

IIL  William  W,,  aged  thirty-seven,  a  post-boy,  was  admitted 
April  15,  with  extensive  anasarca  and  some  fluid  in  the  pleura, 
arising  from  Bright's  degeneration  of  the  kidneys.  He  Avae 
treated  with  sesquichloride  of  iron  and  hot-air  baths.  The 
dropsy  diminished  a  little.  On  the  23d  he  got  chilled  by  an 
open  window,  and  on  the  24th  the  dyspnoea  increased  very  much, 
his  previously  sero-mucous  expectoration  acquired  rusty  brown 
color,  and  there  was  extensive  fine  crepitation  in  the  lower  lobes 
of  both  lungs.  He  was  cupped  between  the  shoulders,  and  a 
small  quantity  (six  ounces)  of  blood  taken.  A  jacket  poultice 
was  kept  round  his  chest,  and  he  took  5ss  of  ether,  and  ITjx  of 
chloric  ether  every  three  hours,  and  four  ounces  of  gin  daily. 
The  dyspnoea  was  somewhat  alleviated  by  these  means,  and  on 
the  27th  the  sputa  became  gradually  purulent,  instead  of  rusty. 
On  the  29th  it  was  still  more  purulent  and  copious.  With  the 
increased  dyspnoea,  induced  by  the  attack  of  pneumonia,  the 
anasarca  of  the  arms,  chest,  and  upper  part  of  the  body  gene- 
rally had  very  much  increased. 

In  this  man's  case  the  imminent  danger  arising  from  the 
pneumonia  has  indeed  almost  passed  away,  and  the  increased 
drops}^  of  the  upper  extremities,  arising  from  the  extra  impedi- 


258  PNEUMONIA. 

ment  to  the  passaoje  of  blood  through  the  lungs,  is  alleviated ; 
but  I  fear  that  his  broken  state  of  health  forbids  our  hoping  for 
his  final  recovery.  You  may  remark,  however,  that  alcoholic 
stimulants,  which  certainly  do  not  benefit  albuminariacs  in  gene- 
ral, are  here  well  borne  and  decidedly  beneficial  while  the  pneu- 
monia is  acute,  and  that  they  have  sustained  the  patient  while 
ready  to  perish.  They  have  also  not  produced  any  tendency  to 
coma  (which  is  so  much  to  be  dreaded  in  these  circumstances), 
but  have  aided  restorative  action. 

This  person  had  hardly  a  spark  of  life  to  spare,  so  as  to  allow 
of  blood-letting  to  any  extent,  and  it  was  only  the  imminent 
danger  of  death  by  congestion  that  induced  me  to  employ  the 
cupping. 

[The  man  died  towards  the  end  of  May  of  gradually  increas- 
ing dropsy  in  all  the  serous  sacs  and  anasarca.  The  pulmonary 
tissue  at  the  back  part  of  both  lungs  was  scarcely  crepitant. 
But  it  was  not  dark  and  congested,  as  is  usual  in  cases  of 
dropsy.  It  was  mottled  with  yellow,  as  if  it  had  been  solidified 
by  the  pneumonia  and  were  recovering.  The  kidneys  were  mot- 
tled and  granular,  not  shrunken.  His  case  is  again  alluded  to 
a  few  pages  on.] 

IV.  George  P.,  aged  twenty-seven,  a  coachman,  was  warded 
on  April  14.  He  had  had  a  cough  for  four  days.  On  the  loth 
he  felt  very  ill,  and  in  the  evening  of  the  same  day  an  erup- 
tion of  measles  came  out.  His  nose  had  been  bleeding  a  little. 
His  tongue  was  pretty  natural ;  the  pulse  88 ;  the  respiration 
32  in  a  minute.  There  was  fine  crepitation  without  dullness 
on  percussion  beneath  the  right  scapula.  He  was  ordered  ten 
leeches  beneath  the  right  scapula  that  day,  and  ten  the  next, 
and  a  half-jacket  poultice.  He  drew  his  breath  much  more 
easily  after  each  application  of  the  leeches.  Dullness  on  per- 
cussion in  the  aifected  part,  which  Avas  noticed  on  the  16th,  had 
disappeared  on  the  18th,  and  he  took  quinine  till  he  left  us  on 
the  oOth,  the  dullness  gradually  merging  into  moist  crepitation 
of  return.  His  cervical  glands  swelled  as  the  eruption  went 
off,  and  he  had  half  a  dozen  leeches  and  hot  fomentations  to  that 
part. 


PNEUMONIA.  259 

Here,  contrary  to  what  I  remarked  in  the  hist  case,  there 
was  plenty  of  life  and  vigor.  Very  probahly  the  man  would 
have  got  over  his  pneumonia  well  under  any  circumstances,  but 
the  leeching  certainly  relieved  his  deep  pain  in  the  side  (the 
stitch  of  congestion)  and  I  think  it  made  things  more  safe.  For 
in  measles  the  pneumonia  is  the  variety  conventionally  named 
"  catarrhal  pneumonia,"  that  is  to  say  beginning  with  and  ari- 
sing from  bronchial  catarrh,  and  is  very  apt  to  go  on  spread- 
ing. It  does  not  come  on  as  it  were  with  a^gush,  and  involve  at 
once  at  the  pulmonary  tissue  it  is  going  to  involve,  but  creeps 
onwards  from  lobule  to  lobule  in  a  troublesome  manner  unless 
checked. 

This  is  familiar  enough  to  those  who  have  much  to  do  with 
measles,  but  I  do  not  think  I  had  an  opportunity  of  remarking 
it  to  you  before,  because  we  so  seldom  have  a  example  of  that 
disease  in  our  wards.  Occurring  mostly  in  children,  and  being 
in  them  a  malady  of  small  moment  unless  complicated  with  pneu- 
monia, it  is  rarely  admitted  into  a  general  hospital. 

The  swelling  of  the  cervical  glands  is  common  in  all  zymotic 
diseases,  and  had  nothing  to  do  with  the  pneumonia. 

V.  Samuel  F.,  aged  twenty-eight,  a  laborer,  was  seized  on 
April  11,  with  a  stitch  in  the  right  side  and  dyspnoea.  I  saw 
liim  on  the  14th.  There  Avas  fine  crepitation  and  comparative, 
but  far  from  absolute,  dullness  on  percussion  in  the  lower  half  of 
the  right  lung.  The  expectoration  contained  some  streaks  of 
blood,  and  was  a  little  yellowish.  He  had  previously  had  six 
leeches  on  his  side.  I  ordered  him  sixteen  more  and  a  jacket 
poultice.  On  the  16th  the  expectoration  was  rusty,  and  his  nose 
had  been  bleeding.  His  bowels  were  open  for  the  first  time 
since  his  illness.  His  pulse  was  lO-l,  and  soft.  He  had  had  de- 
lirium on  the  previous  night.  His  tongue  and  hands  were  tremu- 
lous, and  the  tongue  had  a  yellowish  tinge  like  that  produced  by 
chewing  tobacco,  which  however  he  had  not  been  doing.  He  was 
ordered  ll^x  of  laudanum  every  four  hours,  six  ounces  of  port 
wine  daily,  and  a  teacup  of  beef-tea  hourly. 

By  the  22d  the  crepitation  of  return  was  heard,  though  the 
expectoration  continued  to  exhibit  a  yellowish  tinge  mixed  with 


260  PXEUMOXIA. 

the  pus  of  wliicb  its  bulk  consisted.  lie  was  ordered  quinine, 
mutton  chop  and  porter  in  place  of  the  laudanum  and  teacup 
diet.  I 

On  the  29th,  cough  and  expectoration  had  ceased. 

Here  the  opiate  treatment  of  pneumonia  vras  adopted.  I 
think  it  especiall}^  suited  to  cases  Avhere  there  is  evidence  of  de- 
ficient power  in  the  nervous  system,  where  there  is  great  pros- 
tration or  tremor  of  the  hands  and  tongue.  Where  also  the 
tongue  has  a  smooth  whitey-brown-pnper  colored  coat.  I  give 
it  also  where  there  is  diarihoea,  or  even  any  tendency  to  diarrhoea, 
such  as  two  fluid  motions  daily,  in  pneumonia  :  for  of  all  unfor- 
tunate complications  there  is  none  so  bad  as  looseness  of  bowels: 
those  patients  alw;iys  do  best  who  are  constipated  either  natu- 
rally or  artificially. 

When  in  consultation  you  are  obliged  to  defer  to  the  opinion 
of  others,  and  give  either  mercury  or  antimony,  especially  the 
latter,  in  pneumonia,  always  make  a  proviso  that  a  good  dose  of 
laudanum  shall  be  joined;  it  prevents  a  great  deal  of  the  harm 
which  normally  results  from  the  use  of  those  minerals. 

It  is  remarked  several  times  in  the  note-book  that  no  drowsi- 
ness was  produced,  although  opium  was  given  to  the  extent  of 
three  grains  daily.  This  is  characteristic  of  its  action  in  acute 
inflammations,  when  it  proves  beneficial.  Where  the  soporific 
efi"ect  is  fully  manifested,  I  have  not  found  that  it  has  agreed  so 
well. 

You  will  find  it  recorded  in  the  case-book  on  the  18th  that 
the  pulse  was  "reduplicating."  This  is  rather  an  awkward  at- 
tempt to  translate  Galen's  term  6iKpoTog,  a  character  of  arterial 
beat  graphically  compared  by  him  to  the  stroke  of  a  hammer 
brought  down  loosely  on  an  anvil,  which  rebounds  and  so  gives 
a  second  little  stroke  afterwards.  It  seems  he  often  found  it 
in  the  malarious  fevers  of  southern  Europe,  and  observed  that  it 
indicated  an  approaching  crisis.  I  should  think  that  very  prob- 
able, for  it  seems  to  me  to  arise  from  the  renewal  of  the  natural 
course  and  force  of  the  circulation,  when  that  return  to  health  is 
associated  with  weakness  of  the  cerebro-spinal  system — when  the 


PNEDMONIA.  261 

restored  strength  of  the  muscular  tissue  is  not  supported  by  a 
corresponding  renovation  of  nervous  function.  It  is  an  indica- 
tion for  the  use  of  alcohol  and  opium,  I  think,  although  I  have 
not  observed  it  often  enough  to  be  sure. 

VI.  Jane  W.,  a  joung  "vvife,  mother  of  one  child,  and  six 
months  pregnant  Avith  her  second,  was  admitted  April  12. 
She  had  been  quite  well  on  the  morning  of  the  previous  day, 
till  she  was  taken  with  sickness  and  cold  shivers  at  9  A.M.  Be- 
tween 12  and  1  p.m.  pain  came  on  in  the  left  side  accompanied 
by  dyspnoea.  She  Avas  treated  with  sixteen  leeches,  in  two  de- 
tachments, to  the  left  side,  jacket  poultice  and  hydrochloric 
acid.  On  the  14th  the  case  was  identified  as  one  of  pneu- 
monia by  fine  crepitation  in  the  whole  lower  half  of  the  left 
lung  with  very  slight  comparative  dullness  on  percussion,  and 
a  grain  of  opium  every  three  hours  was  prescribed.  The  next 
day  no  sleepiness  having  been  induced,  and  the  tongue  being 
yellowish,  w^iite  and  pasty,  she  was  ordered  wine,  but  it  seemed 
to  cause  vomiting,  and  was  left  off  next  day.  The  pulmonary 
crepitation  was  succeeded  by  absence  of  breath-sounds  and 
increased  dullness.  On  the  21st  crepitation  (of  return)  Avas 
heard,  the  appetite  came  back,  and  quinine  was  prescribed  in- 
stead of  the  opium.  She  was  discharged  cured  on  the  22d. 
The  vomiting,  due  probably  in  part  to  her  pregnancy,  did  not 
recur. 

There  is  nothing  to  be  remarked  in  this  case  respecting  the 
pneumonia  and  its  opiate  treatment,  beyond  the  fact  of  the 
advanced  pregnancy,  which  seems  to  have  off'ered  no  impediment 
to  its  success.  You  may  observe  that  wine  in  a  young  person 
unused  to  stimulants  produced  vomiting,  which  ceased  on  its 
omission  after  the  trial  of  a  few  glasses.  Vomiting  in  preg- 
nancy is  very  often  the  consequence  of  persistence  in  taking 
alcoholic  drinks.  Alcohol  is  familiarly  known  to  be  an  emetic 
when  swallowed  in  excess,  and  in  the  sensitive  state  of  the  ab- 
dominal and  thoracic  nervous  system  which  accompanies  preg- 
nancy, a  very  small  quantity  is  in  fact  an  excess,  so  far  as  this 
effect  is  concerned.     Foolish  women,  feeling  Avhat  they  term 


202  PNEUMONIA. 

"weak"  from  the  extra  weight  of  the  body  they  have  to  carry 
during  pregnancy,  and  perhaps  also  glad  of  an  excuse  for  in- 
dulgence, sometimes  take  an  additional  quantity  of  wine  or  beer 
at  this  time,  and  are  punished  by  troublesome  vomiting.  This 
can  often  be  checked  at  once  by  making  them  leave  off  the 
stimulant,  and  take  only  light  digestible  food  in  frequent  small 
quantities. 

You  may  remark  that  she  was  put  upon  hydrochloric  acid  for 
a  couple  of  days.  This  was  on  her  first  admission,  when  the 
prostration,  more  than  usual  in  single  pneumonia,  and  caused 
probably  by  her  journey  to  the  hospital,  made  us  suspect  typh- 
fever.  However,  absence  of  delirium,  of  cutaneous  eruption,  and 
of  any  other  signs  of  that  fever,  set  the  question  at  rest  very 
soon,  and  fine  crepitation  in  the  pulmonary  tissue  pointed  out  the 
true  disease. 

{Clinical,  St.  Manjs,  May  30,  1863.) 

I  shall  resume  the  subject  of  pneumonia  with  a  few  additional 
cases. 

VII.  Elizabeth  M.,  a  girl  of  sixteen,  was  taken  ill  on  May  23, 
with  drowsiness,  nausea,  vomiting,  pain  in  her  back  and  limbs, 
and  in  short  the  usual  symptoms  of  typh-fever.  On  her  admis- 
sion, two  days  afterwards,  these  were  more  decided,  and  the 
tongue  was  dry  and  brown  in  the  center.  But  there  were  no 
fever  spots,  nor  have  any  appeared  since.  She  had  some 
diarrhoea  on  admission,  and  there  was  pain  on  pressure  of  the 
left  iliac  fossa.  On  examination  of  the  chest  we  found  fine  crepi- 
tation and  slight  comparative  dullness  in  the  left  lower  lobe,  and 
this  has  since  extended  in  a  minor  deg-ree  to  the  risiht  lower 
lobe.  On  further  examination  we  found  also  a  valvular  murmur 
with  the  first  sound  of  the  heart  on  the  left  side  of  the  apex, 
very  local  and  scarcely  heard  at  the  center  of  the  heart,  probably 
due  to  valvular  disease  from  an  attack  of  acute  rheumatism  two 
years  ago. 

The  only  additions  made  to  the  usual  treatment  of  typh-fever 
were  six  leeches  beneath  the  shoulder-blade,  a  jacket  poultice, 


PXEUMONIA.  263 

and  ten  grains  of  compound  kino  powder  three  times  during  the 
first  day. 

The  case  is  distinguished  by  the  very  early  occurrence  of 
pneumonia  in  typh-fever.  It  is  not  a  mere  congestion  from  the 
long  gravitation  of  poisoned  blood  in  the  sluggish  tissue,  accord- 
ing to  the  commoner  history  of  such  accidents;  but  it  began  the 
first  day  or  the  second  day  of  the  disorder.  The  probable  ex- 
planation of  this  is  the  imperfection  of  the  girl's  heart,  by  which 
the  circulation  was  more  than  ordinarily  retarded.  Observe 
how  laten  the  lung  symptoms  are :  they  came  on  quite  unawares 
to  the  patient  or  her  friends,  and  the  lesion  Avas  made  evident 
only  by  auscultation.  It  is  usually  so  in  typhous  pneumonia; 
for  the  normal  sensitiveness  of  the  system  is  blunted  by  the  poi- 
son, which  by  its  effects  might  almost  be  called  a  narcotic  poison, 
only  that  it  does  not  produce  true  sleep.  This  is  a  warning  to 
be  very  industrious  in  not  neglecting  the  use  of  your  ears  in  all 
cases  of  typh-fever. 

The  compound  kino  powder  was  ordered  for  the  purpose  of 
putting  an  immediate  stop  to  the  diarrhoea.  The  hydrochloric 
acid  would  have  done  that  gradually  in  twelve  or  twenty-four 
hours,  but  a  purged  state  of  the  bowels  is  such  a  pernicious 
circumstance  in  pneumonia,  that  I  was  in  a  greater  hurry  than 
usual  to  arrest  it. 

VIII.  Timothy  MacC,  is  a  burly  hard-drinking  brickmaker, 
aged  about  twenty-seven,  whom  ^ye  saw  first  in  bed  May  27. 
He  was  too  ill  to  tell  a  consistent  tale,  but  he  stated  that  he  had 
been  quite  well  till  the  22d,  Avhen,  on  getting  up  in  the  morn- 
ing, he  was  seized  with  a  trembling  so  severe  that  he  could 
hardly  dress  himself,  and  was  nearly  two  hours  trying  to  do  so. 
These  "trembles"  continued  on  admission;  he  could  not  hold 
his  hand  out  straight,  and  said  that  when  alone  he  saw  flocks  of 
sheep  scampering  past  and  shadows  of  persons  not  really  present. 
He  had  a  hard  bad  cough,  and  his  sputa  was  rusty  and  copious, 
with  pus  in  it.  On  the  right  side  of  the  chest,  both  in  front  and 
behind,  there  was  a  diminution  of  vocal  resonance,  dullness  on 
percussion,    a3gophony,    and  coarse   bronchial   breathing.      On 


264  PNEUMONIA. 

the  left  side  tlicre  was  dullness  on  percussion  in  the  lower 
lobe  behind,  bronchophony  and  coarse  rales.  In  the  front  of  the 
same  side  tiiere  was  puerile  respiration.  There  was  also  stitch 
under  the  ribs  and  pleuritic  friction  on  both  sides.  The  respi- 
rations were  twenty-four,  the  pulse  112  in  a  minute. 

He  was  ordered  ten  drops  of  laudanum  in  effervescing  am- 
monia draughts  three  times  a  day,  jacket  poultice,  teacup  diet, 
and  eight  ounces  of  port  wine  daily. 

On  the  28th  the  pulse  was  120,  the  respirations  forty-two. 
He  was  very  delirious.  A  pint  of  bottled  stout  was  ordered  in 
addition  to  the  wine. 

He  died  early  on  the  29th — two  days  after  admission.  No 
post-mortem  examination  was  allowed  by  the  friends,  who  carried 
off  the  corpse  directly. 

This  is  that  severe  form  of  pneumonia  which  not  uncommonly 
supervenes  on  delirium  tremens  in  hard  drinkers  much  exposed 
to  the  weather.  The  nervous  symptoms  are,  in  proportion  to 
their  prominence,  an  unmistakable  warning  to  avoid  depressants 
and  to  keep  up  the  patient's  strength  by^  all  the  means  in  your 
power.  Bleeding  such  a  man  would  probably  kill  him  in  raving 
mania,  and  I  would  not  venture  even  to  cup  or  leech  him,  useful 
as  it  would  probably  be  to  such  a  state  of  lung  in  a  temperate 
strong  person.  Alcohol  must  be  given  Avithout  stint ;  but  yet  I 
fear  that  however  active  and  unsparing  your  hand  may  be  you 
will  still  lose  the  greater  number  of  your  patients  wdiose  pneu- 
monia comes  on  in  the  course  of  delirium  tremens. 

IX.  George  F.,  aged  twenty-three,  was  attacked  on  the  3d 
of  May  with  rigors,  and  about  four  hours  afterwards  felt  a 
severe  lancinating  pain  in  the  right  side,  much  increased  by 
inspiration.  He  was  sent  up  to  bed  as  an  urgent  case  in  the 
evening,  with  great  dyspnoea,  a  short  sharp  pulse,  and  dullness 
on  percussion  in  the  lower  part  of  the  right  thorax.  It  seemed 
to  be  a  case  of  pleurisy,  and  the  house-surgeon  ordered  him  mer- 
curials and  salines,  and  applied  leeches  to  the  painful  part.  On 
the  6th,  when  I  first  saw  him,  the  sputa  had  become  tawny  and 
speckled  with  blood.  At  that  date,  although  the  dullness  on 
percussion  was  less  marked  than  on  admission,  it  was  still  pres- 


PNEUMONIxV.  265 

ent,  but  all  over  the  infra-scapular  region  on  the  right  side  and 
partially  on  the  left,  there  was  fine  crepitation.  He  was  then 
enveloped  in  a  jacket  poultice,  and  given  seven  minims  of  lauda- 
num every  three  hours.  On  the  0th  the  sputa  was  still  more 
bloody,  and  he  was  ordered,  in  addition  to  the  opium,  tincture 
of  bark  and  ammonia  and  port  wine.  Two  or  three  days  after 
we  found  the  respiration  quite  absent  in  the  lower  lobes,  though 
there  was  large  bronchial  breathing.  But  on  the  16th  crepita- 
tion began  to  return  on  the  right  side,  and  on  the  18th  some  on 
left  side  too — a  joyful  sound  !  By  the  20th  it  was  well  marked 
and  clear  on  both  sides,  and  I  thought  myself  justified  in  allow- 
ing him  ordinary  diet  and  porter,  though  the  sputa  was  still 
partially  tawny  and  purulent. 

Since  then  he  has  been  steadily  improving,  with  the  assistance 
of  a  blister  to  the  right  side,  where  some  pain  was  felt,  and  yes- 
terday he  got  up  and  partially  dressed  himself. 

There  are  two  directions  from  which  pneumonia  attacks  the 
lungs ;  it  begins  either  from  the  inside,  that  is  to  say  from  the 
bronchial  mucous  membrane,  in  which  event  it  constitutes 
catarrhal  pneumonia,  or  the  "suffocative  catarrh"  of  our  fore- 
fathers ;  or  from  the  outside,  when  it  may  be  fairly  named 
pleuropneumonia.  The  latter  is  exemplified  by  the  present  case. 
I  should  say  that,  as  a  rule,  the  chief  danger  of  catarrhal  pneu- 
monia was  at  the  first  onset  of  the  illness,  when  it  sometimes 
ends  very  rapidly ;  while  pleuropneumonia  causes  about  an 
equal  degree  of  danger  throughout,  till  convalescence  begins. 
And  convalescence  is  generally  in  such  cases  very  slow,  the 
destroyed  pleura  not  allowing  the  restored  lung  to  expand  freely 
so  as  to  dilate  the  air-cells.  The  tissue,  therefore,  is  apt  to 
remain  condensed. 

I  dare  say  you  wondered  to  see  me  order  for  a  man,  whose 
lungs  were  in  such  a  state  as  to  cause  dullness  on  percussion 
and  crepitation,  beef  and  porter  like  a  laborer  at  work.  But  I 
reckoned  that  where  there  was  vitality  enough  in  the  system 
to  cause  so  quickly  the  returning  sound  of  expansion,  there  was 
vitality  enough  to  digest  normal  victuals.  I  do  not  say  you  can 
always  succeed  in  getting  solid  meat  digested  thus  early,  but 
where  you  can,  it  shortens  the  convalescence  very  much. 


2G6  PNEUMONIA. 

The  mention  of  returning  crepitation  after  pneumonia  induces 
me  to  recall  to  your  memory  a  post-mortem  examination  which 
took  place  a  fortnight  ago  on  a  patient  about  whom  I  lectured 
on  May  2  (William  W.)*  admitted  for  anasarca  from  diseased 
heart  and  kidneys,  who  died  in  the  course  of  recovery  from 
intercurrent  pneumonia.  I  say  "  in  the  course  of  recovery," 
because  the  pulmonary  tissue  had  again  become  partially  per- 
vious to  air,  and  the  sanguineous  expectoration  had  ceased. 
After  death  we  were  able  to  see  what  pathological  condition 
these  signs  indicated  during  life.  The  tissue  of  the  back  part 
of  each  lung  was  barely  crepitant,  but  it  floated  in  water  and 
admitted  some  air.  It  was  mottled,  as  if  measle-spotted,  with 
yellow  and  red :  on  pressing  it  hard  a  small  quantity  of  thick 
fibro-purulent  stuff  could  be  squeezed  out  from  the  yellower 
portions,  but  the  others  seemed  quite  empty.  It  was  consoli- 
dated luno;  recovering. 

I  have  no  doubt  in  my  own  mind,  that  the  way  in  which  con- 
solidated lung  recovers,  is  by  the  exudated  fibrin  breaking  down 
into  pus  and  being  expectorated,  while  the  obstructed  air-vesicles 
regain  their  elasticity  and  capacity  for  performing  their  func- 
tions. This  is  a  strong  argument  for  an  ample  supply  of  nutri- 
ment during  the  regenerative  process. 

You  may  have  remarked,  both  from  the  progress  of  this  pati- 
ent, who  is  slowly  recovering,  and  from  the  post-mortal  appear- 
ance of  the  lungs  in  the  one  who  died  from  other  causes  during 
convalescence,  that  pneumonia  is  not  a  sudden  attack,  which 
strikes  at  once  all  the  pulmonary  tissue  that  is  going  to  be  affect- 
ed. Its  onward  march  is  gradual ;  it  creeps  on  from- spot  to  spot, 
and  from  lung  to  lung.  And  its  backward  march  is  gradual  too ; 
the  parts  first  paralyzed  in  their  functions  recover  first,  and 
those  last  wounded  recover  last.  This  too  they  do,  in  spite  of 
the  latter  being  perhaps  the  least  affected. 

It  is  from  observations  like  these  that  the  great  advantage  of 
our  post-mortem  examinations  is  derived.  The  chief  cause  of 
death  is  often  the  least  noteworthy  fact  about  them.  In  nine 
cases  out  of  ten  it  is  some  utterly  irremediable  organic  lesion, 

*  See  page  257. 


PNEUMOXIA.  267 

the  siglit  of  which  merely  flatters  your  vanity  by  verifying  your 
diagnosis.  But  the  lesions  which  do  not  kill,  and  which  are 
curable,  are  those  you  are  concerned  with,  and  to  understand 
which  makes  you  good  practitioners. 


{Clinical,  St.  Marijs,  July  11,  1868.) 

George  F.,  about  Avhom  I  lectured  to  you  six  weeks  ago,  has 
justified  by  the  slowness  of  his  convalescence  the  distinction  I 
pointed  out  to  you,  between  pneumonia  commencing  from  the 
interior  of  the  lung  and  from  the  outside.  The  lower  right 
lobe  still  remains  dull  on  percussion,  and  air  is  very  sparingly 
admitted  into  it.  Some  parts  of  the  puhnonary  tissue  has  also 
broken  down  into  a  small  abscess  in  the  front  part  of  the  lower 
lobe.  He  has  fortunately  no  hectic,  and  is  getting  strong  and 
stout  slowly  upon  iodide  of  iron  and  cod-liver  oil.  The  ribs  will 
probably  fall  in  on  that  side  just  as  they  do  after  empyema, 
but  we  shall  not  be  able  to  keep  him  in  the  hospital  long  enough 
for  you  to  see  the  result. 

Two  other  cases  of  pneumonia  were  taken  in  yesterday  week. 

X.  Mary  P.,  a  child  just  at  the  age  of  puberty,  was  admitted 
July  2.  She  had  had  cough  and  cold  for  a  short  time,  but  did 
not  give  up  her  work  as  a  domestic  servant  till  the  morning  of 
her  admission,  when  she  was  taken  very  ill,  with  shortness  of 
breath.  On  admission  the  breathing  was  very  labored,  and  she 
raised  the  alae  nasi  in  inspiration.  The  respirations  were  44  in 
the  minute ;  the  pulse  144.  There  was  bronchial  breathing  and 
whistlinfj  riiles  all  over  the  chest.  The  wdiole  of  the  v\^\\t  lower 
lobe  was  dull  on  percussion.  No  stitch  in  the  side,  or  pain  on 
pressure.  She  was  cupped  to  oiv  between  the  shoulders,  eight 
leeches  were  applied  beneath  the  shoulder-blades,  and  the  chest 
was  enveloped  in  a  jacket  poultice.  I  also  ordered  her  TT|x  of 
laudanum  every  three  hours  and  tea-cup  diet. 

On  the  4th,  when  I  came  round,  she  was  asleep,  and  the 
respiration  was  evidently  so  much  relieved  that  I  did  not  care 
to  waken  her.     She  had  expectorated  some  blood-stained  mucus. 

On  the  5th  the  pulse  was  130;  the  respirations  30. 


268  PNEUMONIA. 

On  the  8tli  the  pulse  was  120  ;  the  respirations  26.  The  dull- 
ness, on  percussion,  extended  half  way  up  the  right  lung,  and 
coarse  crepitation  had  succeeded  to  the  whistling  rales.  The 
tongue  was  brown  ;  but  that  did  not  seem  caused  by  any  aggra- 
vation of  the  symptoms.  On  inquiry,  I  found  she  had  been 
sleeping  that  night  and  morning  much  more  than  usual,  and 
suspected  that  the  brown  coat  of  epithelium  was  caused  by  the 
oj)ium.     I  left  off  all  medicine,  and  trusted  to  the  poultice  only. 

On  the  9th  her  tongue  was  clean. 

To-day  (the  11th),  the  respirations  are  natural,  and  the  air 
enters  freely  to  the  base  of  the  lung,  which  is  resonant  on  per- 
cussion. Only  on  a  full  inspiration  can  you  hear  a  little  crack- 
ling in  the  pulmonary  tissue.  The  sputa  is  purulent,  with  a 
slight  orange  tinge  in  some  parts.  She  says  her  bowels  have 
not  been  opened  the  last  six  days.  She  makes  so  much  account 
of  this,  that  I  have  given  her  a  dose  of  castor-oil,  to  quiet  her 
mind ;  though  really  the  constipation  is  a  good  thin.g  in  pneu- 
monia. 


Remark  in  this  girl  how  severe  the  symptoms  were  at  first, 
how  dangerous  indeed  to  life,  yet  how  soon  the  alarming  part  of 
them  passed  away.  This  would  not  have  been  tlie  case  if  she 
had  had  pleuritic  pneumonia,  instead  of  the  catarrhal  or  bron- 
chitic  form  of  the  disease. 

The  opium  agreed  with  her  very  well,  but  ten  drops  every 
three  hours  is  a  large  dose  for  a  child ;  and,  therefore,  when  it 
did  not  seem  to  be  demanded  by  the  symptoms,  I  was  glad  to 
leave  it  off.  You  will  usually  find  that  the  time  for  doing  so  is 
marked  by  tolerance  ceasing,  and  increased  drowsiness  coming  on. 

XI.  George  L.,  a  muscular  laborer,  aged  thirty-two,  came 
under  my  care  July  3.  He  confessed  to  being  a  hard  drinker, 
and  to  having  had  several  attacks  of  delirium  tremens.  After 
ailing  for  a  few  days  to  such  an  extent  only  as  allowed  him  to  go 
on  with  his  work,  he  was  taken  on  June  30  with  rigors  and 
dyspnoea,  so  as  completely  to  prostrate  him.  When  I  saw  him 
the  respirations  were  60  ;  the  pulse  small,  140  ;  his  tongue  thickly 


PNEUMONIA.  2G9 

coated.  The  skin  w.as  hot  and  diy,  and  there  was  an  eruption 
of  herpes  on  the  lips.  There  was  dullness  on  percussion,  with 
bronchial  breathing,  in  the  whole  of  the  right  lower  lobe,  and 
dullness  less  decided  in  the  lower  part  of  the  left  lower  lobe, 
Avith  fine  crepitation  at  the  upper  level  of  the  dullness.  He  was 
cupped  to  .jviij  beneath  the  shoulder-blades,  put  in  a  jacket  poul- 
tice, and  ordered  twenty  minims  of  laudanum  everj  four  hours, 
and  tea-cup  diet  every  two  hours. 

On  the  4th  the  pulse  was  130,  larger  and  fuller;  the  respira- 
tion 44. 

On  the  5th  the  pulse  was  120,  the  respiration  40.  I  found 
him  raised  in  bed  and  reading  a  newspaper. 

On  the  6th  the  pulse  was  132  ;  the  respirations  36.  He  had 
been  noisy  and  delirious  the  night  before.  Four  ounces  of  port 
were  ordered  to  be  added  to  the  treatment,  to  be  taken  at  night. 

On  the  7th  tawny  expectoration  commenced. 

On  the  8th  pulse  108  ;  respirations  36. 

To-day  (the  11th),  his  pulse  is  100;  the  respirations  26;  the 
air  enters  freely  into  the  right  lower  lobe,  with  only  a  certain 
coarseness  on  full  inspiration.  That  part  is  also  resonant  on 
percussion.  In  the  left  lower  lobe  a  slight  comparative  dullness 
remains,  and  there  are  the  crackles  of  returning  breath  sounds. 

The  lung  tissue  you  see  has  returned  to  its  allegiance  in  the 
order  in  which  it  ceased  to  work.  First  the  right  lower  lobe, 
which  was  the  most  condensed  on  admission,  and  was  the  first 
affected  ;  then  the  left  lower  lobe,  which  was  the  last  to  suffer, 
and  is,  therefore  the  last  to  get  well.  Pneumonia  does  not  strike 
like  a  thunderbolt  the  whole  that  is  going  to  be  injured,  but 
creeps  on  from  one  spot  to  another,  and  creeps  away  in  the  same 
order. 

The  remark  which  I  made  apropos  of  the  last  case  as  to  the 
form  of  pneumonia,  and  the  alarming  earliness  of  its  severe 
symptoms,  applies  equally  to  this  man.  Though  his  breathing 
was  so  short,  and  his  pulse  so  quick  on  the  4th,  yet  on  the  5th 
he  had  strength  enough  to  be  reading  his  Sunday  newspaper. 
But  the  exertion  was  as  bad  for  his  body  as  the  politics  doubtless 
18 


270  PNEUMONIA. 

were  for  his  mind,  and  in  the  evening  he  got  delirious,  and  was 
inconveniently  violent  during  the  night.  I  had  hoped  to  spare 
our  wine,  but  was  forced  by  this  delirium  to  order  him  a  couple 
of  glasses  of  port  to  be  taken  every  evening. 

You  may  learn  by  this  instance  how  important  quiet  is  in 
pneumonia  both  for  mind  and  body.  Nearly  all  our  dangerous 
and  fatal  cases  are  made  dangerous  and  fatal  by  neglect  of  this  ; 
and  though  this  patient  is  not  seriously  injured  by  his  imprudent 
obstinacy,  yet  I  have  no  doubt  his  convalescence  will  be  the 
longer  for  it,  and  we  have  had  to  give  him  stimulants  which 
might  possibly  have  been  spared.  If  the  stimulancs  had  not 
been  given,  he  would  very  likely  have  had  delirium  tremens ; 
the  lungs  Avould  have  become  more  congested,  and  he  might 
have  died  like  a  man  I  lectured  about  on  a  late  occasion.  (See 
Case  VIIL) 

When  I  say  this,  however,  I  ought  to  guard  my  words.  For 
in  reality  he  would  not  have  been  in  anything  like  the  danger  of 
that  poor  fellow.  Truly  enough  the  two  diseases  are  a  most 
perilous  combination ;  but  it  makes  a  great  deal  of  difference 
whether  the  pneumonia  is  a  consequence  of  an  antecedent  deli- 
rium tremens,  or,  whether  the  delirium  tremens  is  a  consequence 
of  the  pneumonia  coming  on  a  predisposed  subject.  In  the 
former  case  a  fatal  result  almost  invariably  happens,  but  not  so 
in  the  latter.  So  that  though  he  might  have  died,  yet  he  would 
not  have  been  so  certain  to  die  as  our  former  patient. 

XII.  A  little  boy,  four  years  old,  was  conveyed  here  on  the 
3d  instant,  just  at  his  last  gasp,  and  died  about  a  quarter  of  an 
hour  after  I  had  seen  him,  while  the  ward-sister  was  putting  him 
into  a  poultice,  and  giving  him  some  wnne  and  beef-tea. 

It  was  entered  in  the  "urgent  admission  book,"  as  a  case  of 
pneumonia;  and  so  there  was  pneumonia,  but  it  had  nothing  to 
do  with  his  death,  which  in  reality  arose  from  the  impaction  of 
a  calculus  in  the  right  ureter  and  inflammation  of  the  kidney 
following  thereon.  The  pneumonia  w^as  a  consequence,  not  a 
cause,  being  of  the  sort  fairly  designated  "  pneumonia  morien- 
tum.'*  It  was  the  consolidation  of  scarce  a  half  of  the  right 
lower  lobe  by  this  congestion  of  gravitation  which  caused  the 


PNEUMONIA.  271 

patient  to  be  entered  as  I  have  said,  and  placed  in  the  medical 
wards.  Had  that  been  the  only  anatomical  change,  this  child 
might  easily  have  recovered ;  and  I  mention  the  case  only  to 
guard  you  against  crediting  the  death  purely  to  pneumonia. 

The  dozen  cases  of  pneumonia  which  I  have  made  the  subject 
of  a  considerable  portion  of  three  clinical  lectures  since  Easter,* 
may  be  held  to  be  a  fair  representation  of  an  average  four 
months'  hospital  experience  of  the  disease.  There  have  been 
specimens  of  its  most  ordinary  forms  very  much  in  the  propor- 
tions in  which  they  will  occur  to  you  in  practice.  They  have 
included 

2  cases  of  pleuropneumonia,  one  fatal,  one  not ;  (VIII,  IX). 
1  case  of  pneumonia  in  measles ;  (IV). 
1  case  of  pneumonia  in  typh-fever ;   (VII). 
1  case  of  pneumonia  in  Bright's  disease;  (III). 
1  fatal  case  of  pneumonia  relapsing  on  a  previously  consoli- 
dated and  broken-down  lung;  (II). 
5  cases  occurring  in  previously  healthy  persons ;  (I,  V,  VI, 

X,  XI). 
1  case  occurring  as  a  complication  of  the  death-agony  from 

another  disease ;  (XII). 
In  the  fatal  cases  the  death  Avas  caused  in   one  by  the  pneu- 
monia coming  on  a  previously  consolidated  lung  (II),  in  the 
other  on  a  severe  attack  of  delirium  tremens  (VIII).     In  the 
third  the  pneumonia  was  caused  by  the  death  (XII). 

And  as  to  treatment,  I  have  taken  current  opportunities  of 
impressing  upon  you  the  following  rules : — 

I.   Take  blood  locally,  cautiously,  in  the  early  stage  only, 
and  with  a  distinct  reference  to  the  power  of  each 
patient. 
II.  Keep  the  chest  from  first  to  last  enveloped  in  a  jacket 
poultice,  and  allow  of  as  little  movement  as  possible. 

III.  Administer  food  frequently,  largely,  and  in  a  liquid  form. 

IV.  Where  the  nervous  system  is  deeply  smitten,  as  indicated 

*  Viz.,  on  May  2,  May  30,  and  July  11.  They  are  here  massed  together  into 
one  lecture. 


272  PNEUMONIA. 

by    tremulous  muscles,   mental  excitement,   delirium. 

tawny  tongue  at  an  early  stage,  great  depression,  &c., 

give  opium  ;  and  in  some  cases  give  alcohol,  but  not  in 

small  repeated  doses. 
V.  Where  there  is  diarrhoea,  stop  it  immediately  with  opium 

or  kino. 
Vr.   Consider  antimony,  mercury,  and  purgatives  as  poisons 

in  pneumonia. 
I  have  heard  the  plans  of  treatment  which  I  recommend  you 
to  adopt  described  as  "trusting  to  nature;"  and  sometimes  a 
deprecatory  "merely"  is  added — "merely  trusting  to  nature." 
In  one  sense  this  is  true,  for  all  methods  of  cure,  at  least  all  suc- 
cessful methods  of  cure,  must  depend  on  the  regaining  of  natural 
vital  forces ;  and  the  agencies  brought  into  action  by  our  inter- 
ference must  be  the  natural  vital  forces  of  the  body  acted  upon. 
The  heat  and  moisture,  for  example,  which  we  employ  in  pneu- 
monia, are  an  imitation  of  and  compensation  for  the  deficient 
steadiness  of  the  vital  warmth  ;  the  current  of  blood  which  we 
cause  to  flow  with  our  cupping-glasses  is  a  replacement  of  the 
natural  current ;  we  give  opium  to  bring  the  condition  of  the 
nervous  system  into  harmony  with  the  functions  arrested  by  the 
disease.  There  is  no  successful  method  of  cure  but  what  is  suc- 
cessful by  virtue  of  thus  restoring  vitality.  But  in  the  sense 
intended  by  those  who  slightingly  use  them,  the  words  are 
synonymous  with  doing  nothing,  or  leaving  the  patient  to  him- 
self, with  la  medechie  expectcmte,  with  the  contemplatio  mortis  of 
the  satirist,  with  a  hardened  skepticism.  It  is  a  saying  like 
those  clever  sneers  of  Job's  adversary,  which,  under  the  guise 
of  a  truism,  hide  a  lie. 

Doing  nothing  or  leaving  the  patient  to  himself,  would  indeed 
be  dishonest;  but  do  we  do  so?  Is  it  doing  nothing  to  keep  up 
constant  relays  of  poultices  night  and  day  for  a  week  or  ten 
days?  Is  the  enforcement  of  continuous  nutrition  no  labor?  Is 
there  no  anxiety  and  thought  spent  in  hourly  watching  the  need 
of  variation  in  our  doses  of  opium  and  wine  for  serious  cases? 
Is  the  moistening  and  warming  the  air  to  an  even  temperature 
not  enough  to  occupy  our  time  ?     Is  it  so  much  easier  to  sup- 


PNEUMONIA.  273 

port  the  waning  life  than  to  weaken  it,  that  the  former  should 
be  condemned  as  idleness,  the  latter  praised  as  activity?  If  the 
pneumonic  patient  were  left  to  himself  would  he — could  he — 
adopt  any  of  the  means  suitable  for  his  recovery?  Would  he 
not  very  likely  be  taking  colocynth,  senna,  calomel,  antimony, 
ipecacuanha,  salines,  senega,  squill,  hydrocyanic  acid,  colchicum, 
be  rubbing  in  mercury,  applying  mustard  poultices,  and  blisters, 
be  bled  coup  sur  coup,  or  have  brandy  every  half  hour?  Is  it 
nothing  to  stand  sentry  against  the  fatal  seductions  of  poly- 
pharmacy? 


LECTURE    XXII. 

EMPHYSEMA    OF    THE    LUNGS. 

Illustration  of  the  morbid  anatomy  of  emphysema — -Fatty  de- 
generation of  the  'pulmonary  membrane — Degeneration  some- 
times fibroid — Cause  of  the  pr oneness  of  children  s  lungs  to 
become  emphysematous — Question  whether  inspiration  or  expi- 
ration most  tends  to  produce  emphysema — Action  of  the  lungs 
in  breathing  illustrated  by  an  example  of  a  man  without  a 
sternum — Expiration  more  powerful  than  inspiration — Ap- 
plication of  the  morbid  anatomy  of  emphysema  to  clinical 
questions — Case  of  emphysema  in  an  albuminuriac — Case  of 
emphysema  depressing  the  heart — Treatment  and  its  objects — 
Iron —  Tobacco — Lobelia — Stramonium  —  Mercury  —  Alcohol 
— Expectorants — Ttvo  cases  of  emphysema  in  young  women 
exposed  to  adverse  circumstances — Treatment  hy  iron — Trial 
of  expectorants. 

{Clinical,  St.  Marys,  March  13,  1863.) 

The  following  case,  of  which  you  now  see  the  post-mortem 
examination,  is  a  fair  illustration  of  the  morbid  anatomy  of  pul- 
monary emphysema. 

Of  the  diseases  which  the  diseased  had  suifered  from  depen- 
dent on  this  condition,  the  history  was  given  by  him  as  follows: — 

George  W.,  aged  forty-two,  a  temperate  laborer,  much  ex- 
posed by  his  work  to  cold  and  wet,  had  always  "a  good  wind" 
till  three  years  ago.  Since  that  time  he  has  been  what  he  terms 
"asthmatic,"  that  is  to  say,  he  has  been  habitually  short  of 
breath  and  liable  to  contract  catarrh  accompanied  by  dyspnoea 
on  moderate  exposure.  He  was  still  always  able  to  do  an  average 
day's  work  till  last  Christmas,  since  which  time  he  has  been  too 


EMPHYSEMA  OF  THE  LUNGS.  275 

short  of  breath.  He  cannot  assign  any  cause  for  his  illness 
except  exposure  to  cold. 

When  jou  first  examined  him,  March  2,  he  was  breathing 
spasmodically  and  with  extreme  difficulty;  his  lips  and  face  were 
dark  purple,  but  without  any  of  the  bloated  appearance  you  so 
commonly  see  in  cases  of  dyspnoea  from  enlarged  heart.  On 
examining  the  chest  we  found  the  cardiac  region,  as  well  as  the 
whole  lower  part  of  the  thorax,  preternaturally  resonant,  and 
the  ribs  were  bowed  and  raised,  so  as  to  make  the  bony  frame- 
work of  the  upper  half  of  the  trunk  more  globular  than  natural, 
and  to  throw  backwards  the  lower  angle  of  the  scapula.  The 
intercostal  spaces  were  not  protuberant.  The  number  of  respi- 
rations was  thirty-four  in  a  minute,  the  pulse  104.  In  the 
cardiac  region,  and  in  several  other  of  the  lower  parts  of  the 
chest,  I  drew  your  attention  to  a  peculiar  crumpling  sound  in 
inspiration,  not  unlike  that  produced  by  squeezing  up  fine  paper 
in  the  hand. 

He  experienced  a  certain  degree  of  relief  from  the  rest  in 
bed,  and  a  draught  three  times  a  day  containing  lobelia  and 
chloric  ether ;  so  that  on  the  4th  his  respirations  were  reduced 
to  twenty-eight  in  a  minute. 

But  he  soon  fell  back  again,  and  sank  exhausted  and  breath- 
less on  the  11th,  and  we  have  now  to  make  the  post-mortem  ex- 
amination. 

On  opening  the  chest  the  heart  is  seen  completely  overlapped 
and  hidden  by  a  layer  of  lung  about  two  inches  thick,  consisting 
of  lobular  masses  of  pulmonary  tissue,  pale  in  tint,  dilated  into 
vesicles,  and  looking  more  like  flesh-colored  soapsuds  than  any- 
thing else.  These  masses  of  vesicles  are  firm  and  elastic  from 
retained  air;  but  when  that  is  let  off  by  a  puncture,  they  sink 
down  into  a  flabby  non-crepitant  substance.  The  same  appear- 
ance is  seen  in  the  greater  part  of  the  lower  left  lobe,  and  at  the 
apex  of  the  upper  lobe;  and  the  lower  right  lobe  is  partly  in  a 
similar  condition.  The  flesh  of  the  heart  is  pale,  and  its  cavities 
are  large.  The  wall  of  the  left  ventricle  is  thinner  perhaps  than 
natural,  but  the  whole  organ  is  not  so  much  dilated  as  to  render 


270  EMPHYSEMA  OF  THE  LUNGS. 

the  valves  inefficient;  and  thcj  are  healthy  in  appearance.  The 
kidneys  and  other  viscera  are  quite  normal. 

On  the  whole  you  are  perhaps  rather  surprised  at  the  small 
extent  of  obvious  organic  change,  considering  the  violence  and 
fatality  of  the  symptoms.  But  now  examine  again  the  portions 
of  lung  not  aifected  with  these  bullae  of  emphysema.  They  are 
doughy,  flabby,  and  non-elastic.  They  keep  the  mark  of  a  finger 
pressed  upon  them.  There  are  very  slightly  crepitant  when 
squeezed.  You  nuiy  reasonably  feel  dou-ljtful  whether  such  pul- 
monary tissue  can  perform  the  functions  which  require  elasticity 
and  firmness. 

Now  let  us  make  a  section,  and  cut  out  with  a  pair  of  curved 
scissors  a  few  snips  as  fine  as  we  can,  tease  them  out  with  a 
needle,  and  place  them  under  the  microscope  with  a  lens  of  one- 
quarter  inch  focus.  You  thus  get  a  sight  of  the  pulmonary 
membrane.  You  know  it  oun-ht  to  be  a  continuous  skin-like 
membrane,  transparent,  and  distinguished  principally  by  bundles 
of  fibers  gently  curled  and  interlaced.  In  a  healthy  lung  it  does 
not  exhibit  any  cells  or  corpuscles.  But  here  you  see  scattered 
about  it  numerous  fine  dark  specks,  and  somewheres  there  are 
round  bright  globules  with  a  dark  outline,  and  somewheres  the 
globules  and  specks  are  collected  together  into  masses,  denser 

towards    the    center  —  so  o*l**   *t  y<'^'^''° — iust  like  the  masses  of 

fatty  degeneration  which  you  often  witness  in  the  muscular 
structure  of  atrophied  hearts.  This  is  in  fact  an  example  of  the 
same  morbid  state  in  another  tissue,  the  fatty  degeneration  of 
pulmonary  instead  of  cardiac  tissue. 

It  is  easy  to  understand  how  emphysematous  bulliie  arise. 
Melt  one  side  of  an  India  rubber  ball  in  a  candle  and  squeeze 
it;  you  see  it  bulge  out  into  a  bubble  just  in  the  same  way;  and 
just  from  the  same  cause,  loss  of  elasticity.  What  the  melting 
is  to  the  India  rubber  ball  that  to  the  pulmonary  branch  of  vesi- 
cles is  the  wasting  of  its  elastic  web  into  fat.  When  any  dilating 
force  is  exerted  upon  the  walls  of  the  vesicles  they  give  way  and 
do  not  contract  again. 

It  is  not  always  fatty  degeneration  which  is  found  in  emphy- 


EMPHYSEMA  OF  THE  LUNGS.  277 

seraatous  lungs;  sometimes  it  is  fibroid  degeneration,  and  Dr. 
Jenner  has  in  his  experience  found  this  latter  the  most  common.* 
Either  sort  of  partial  interstitial  death  involves  a  loss  of  the 
functions  of  elasticity  and  contractility  in  the  tissue — fatty  de- 
generation probably  the  most  loss,  and  therefore  it  is  that  you 
find  it  in  the  most  rapidly  fatal  and  most  marked  cases,  such  as 
the  one  under  our  eyes.  The  same  softness  and  proneness  to 
give  way  may  also  be  supposed  to  exist  in  the  lungs  of  children; 
for  the  younger  the  tissue  the  softer  it  is;  and  thus  children's 
lungs  are  very  prone  to  become  emphysematous  without  there 
being  any  interstitial  change  to  be  detected  in  the  pulmonary 
tissue. 

The  anatomical  or  predisposing  cause  of  the  disease  we  are 
considering  may  then  be  held  to  be  a  too  great  softness  of 
tissue,  from  the  lung  either  not  having  yet  acquired  its  full 
power  of  resistance  or  from  having  lost  it  by  morbid  change. 

And  now  let  us  look  for  the  external  or  determining  cause, 
quite  as  important  an  element  in  the  production  of  disease.  It 
is  the  fact  of  breathing  of  course,  and  the  act  of  breathing 
forcibly,  that  breaks  down  the  over-soft  tissue.  But  is  it  inspi- 
ration or  expiration  that  is  most  to  blame,  or  both  equally  ? 
The  question  rests  on  the  point  of  which  causes  most  pressure 
of  air  on  the  pulmonary  membrane  of  the  air-cells.  And  because 
inspiration  fills  these  air-cells,  it  has  appeared  to  some  to  cause 
most  pressure  on  their  walls.  Doubtless  in  inflating  a  bladder 
you  increase  the  atmospheric  pressure  on  the  inside,  and  I  sup- 
pose it  must  be  this  analogy  which  has  led  physiologists  astray. 
But  the  cases  are  quite  difi'erent;  the  lungs  are  not  inflated  by 
blowing  air  into  them,  but  by  the  expansion  of  their  walls  draw- 
ing air  into  them,  in  fact  by  the  atmospheric  pressure  on  the 
interior  being  forcibly  lessened  through  the  action  of  the 
diaphragm  and  other  respiratory  muscles.  A  fairer  analogy 
would  be  a  pair  of  bellows,  the  leathern  sides  of  which  are 
certainly  not  bulged  outwards  by  the  filling  of  the  instrument. 
And  if  that  leather  were  softened  it  would  swell  and  stretch  during 
the  blowing  of  the  fire,  not  during  the  drawing  in  of  the  air. 
*  "Medico-Chirurgical  Transactions,"  vol.  xl,  p.  26. 


278  EMPHYSEMA  OF  THE  LUNGS. 

Not  inspiration,  but  expiration,  must  be  the  most  efficient 
determining  cause  of  the  dilatation  of  the  air-vesicles  in  emphy- 
sema. The  difficulty  which  people  feel  in  understanding  this 
arises  from  their  thinking  of  the  thoracic  walls  as  a  contracting 
ball  or  box,  of  equal  contractile  force  throughout,  and  which 
therefore  in  its  contraction  during  expiration  would  equally 
diminish  the  area  of  all  the  pulmonary  vesicles  at  once.  And 
diminishing  the  area,  say  they,  is  certainly  inconsistent  with 
dilitation.  But  this  idea  of  the  chest  is  an  erroneous  one.  The 
thoracic  walls,  from  their  irregular  shape  and  from  their  vary- 
ing solidity  in  various  parts,  press  with  a  very  unequal  degree 
of  force  on  different  parts  of  the  lungs.  The  apices  of  the 
upper  lobes,  for  example,  from  the  deficiency  of  the  bony  frame- 
work above  them,  and  the  edges  of  the  lower  lobes  from  being 
in  an  angle,  escape  the  compression  of  the  ribs  and  diaphragm 
to  a  nYQat  extent.  When  then  the  air  by  the  action  of  the 
respiratory  muscles  is  squeezed  out  of  the  more  readily  com- 
pressed parts,  it  is  driven  into  or  at  least  is  driven  towards  these 
less  compressed  parts. 

Two  or  three  years  ago  some  of  you  were  shown  in  this  theater 
the  action  of  respiration  upon  the  less  compressed  parts  of  the 
lungs  by  a  M.  Groux,  a  poor  gentleman  with  congenital  de- 
ficiency of  the  sternum  and  a  consequent  fissure  in  the  thoracic 
walls,  which  fissure  was  covered  only  by  skin  and  cellular  tissue. 
Of  course  the  portions  of  lung  behind  this  fissure  were  less  com- 
pressed than  any  part  of  the  pulmonary  substance;  and  during 
expiration  you  saw  therii  bulge  out,  just  like  the  leathern  sides 
of  a  bellows  during  a  corresponding  movement.  Those  who 
witnessed  the  curious  sight  admired  the  toughness  of  pulmonary 
tissue  Avhich  could  resist  injury  from  such  an  abnormal  state  of 
things.  And  they  could  not  fail  to  understand  that  if  M.  Groux's 
lungs  had  been  Avanting  in  elasticity,  they  would  never  have  been 
able  to  resist  the  dilating  power  exerted  by  expiration  on  this 
undefended  part  of  the  tissue.  The  same  condition  which  M. 
Groux's  deficiency  of  sternum  exhibited  in  an  exaggerated  way, 
the  normal  partial  deficiency  of  bony  framework  presents  in  a 
less  degree  to  the  apices  of  the  lungs,  and  their  peculiar  angular 


EMPHYSEMA  OF  THE  LUNGS.  279 

position  to  the  bases.  It  is  in  these  parts  that  expiration  causes 
the  atmospheric  pressure  to  be  greatest,  and  it  is  in  these  parts 
that  emphysema  most  commonly  appears,  as  exemplified  in  the 
instance  before  us.  It  is  at  the  apices  and  anterior  edges  of  the 
lungs  indubitably  that  we  most  often  find  this  morbid  state  when 
the  degeneration  is  generally  diffused. 

When  emphysema  appears  elsewhere  in  the  lungs,  the  apices 
and  edges  being  free  from  it,  it  is  due  to  the  degeneration  being 
local,  and  to  those  peculiarly  liable  parts  at  apices  and  bases 
being  shielded  from  injury  by  their  healthy  elasticity. 

Another  reason  for  thinking  that  expiration  rather  than  in- 
spiration is  the  main  cause  of  the  final  injury  to  the  vesicles  in 
emphysema,  is  that  it  is  much  the  most  powerful  of  the  two 
muscular  efforts.  If  a  man  can  draw  in  the  air  through  his 
nostrils*  with  sufficient  force  to  raise  a  column  of  mercury  (say) 
two  inches,  he  can  by  expelling  it  steadily  raise  the  level  2|- 
inches:  if  he  is  strong  enough  to  lift  the  fluid  by  inspiration  2^ 
inches,  his  expiratory  power  will  mark  3|.  Thus,  even  though 
it  is  possible  that  both  inspiration  and  expiration  may  tend  to 
rupture  or  dilate  the  pulmonary  membrane,  inasmuch  as  all 
motion  must  endanger  an  abnormally  friable  tissue,  yet  expira- 
tion tends  to  do  so  much  the  most.  This  is  the  real  practical 
point ;  as  I  will  show  you  presently,  when  I  come  to  apply  our 
knowledge  to  its  true  end,  the  relief  of  distress. 

This  fatal  case  then  has  shown  you  the  true  nature  of  the 
anatomical  injury  you  have  to  deal  with  in  emphysema  of  the 
lung.  It  is  an  interstitial  partial  death,  or  degeneration  of  the 
pulmonary  membrane.  This  membrane,  which  forms  the  frame- 
work of  the  vesicles,  thus  loses  its  elasticity  and  is  determined 
to  dilatation  by  the  action  of  forced  expiration. 

It  may  be  asked  whether  the  degeneration  is  not  rather  the 
result  instead  of  the  cause  of  the  dilatation.  It  may  be  sug- 
gested that  bronchitis  and  violent  cough  originate  the  rupture 

*  The  uostrils  must  be  used  in  the  experiment,  because  the  action  of  the 
tongue  and  cheeks  in  suction  and  puffing  introduce  a  fallacy,  bringing  into  use 
muscles  which  are  not  muscles  of  respiration.  See  Dr.  Hutchinson's  paper  in 
"  Medico-Chirurgical  Transactions,"  vol.  xxix,  p.  199. 


280  EMPHYSEMA  OF  THE  LUNGS. 

of  the  vesicles,  and  that  the  ruptured  vesicles,  being  unused,  fall 
like  all  unused  tissues,  into  fatty  decay.  I  Avill  not  deny  the 
possibility  of  such  a  sequence  of  events  in  some  instances,  be- 
cause in  point  of  fact  we  do  not  find  emphysema  of  unaltered 
pulmonary  tissue  in  children.  But  it  was  not  so  in  the  case 
before  us,  because  the  patient  had  not  been  subject  to  bronchial 
catarrh,  had  no  mucous  secretion  before  he  got  short  of  breath, 
and  indeed  had  very  little  even  up  to  the  fatal  termination.  And 
the  case  before  us  is  a  well-marked  type  of  uncomplicated  em-  • 
physema  in  the  adult. 

Do  not  rest  satisfied  with  having  learnt  the  pathology  of  a 
disease  without  applying  the  pathology  to  its  treatment.  If  it 
were  not  capable  of  such  an  application  I  should  not  make  it 
a  subject  for  clinical  lecturing.  The  pathology  of  emphysema 
shows  us  a  gradually  increasing  loss  of  vitality  in  the  pulmonary 
membrane.  We  must  so  treat  the  patient  as  to  increase  the 
vitality.  A  constant  supply  of  nutritious  food  and  long  courses 
of  food  give  the  best  chance  of  doing  this.  I  should  have  adopted 
it  for  our  patient  had  he  lived  long  enough. 

The  pathology  may  teach  something  more.  Expiration  is  the 
dangerous  and  injurious  part  of  breathing,  and  especially  forced 
and  arrested  expiration.  Let  your  patient  carefully  avoid  all 
such  employments  as  strain  the  respiratory  muscles — all  such 
labors  as  make  a  man  hold  in  his  breath  and  then  puff  it  out 
with  a  jerk — such  as  lifting  and  carrying  heavy  weights,  dig- 
ging, pitching,  rowing,  &c.  I  do  not  think  you  need  trouble 
yourselves  about  wind  instruments  or  singing ;  persons  with  em- 
physematous lungs  are  not  likely  to  be  addicted  to  them,  and  as 
a  matter  of  fact  those  who  use  the  chest  freely,  such  as  public 
singers,  do  not  get  emphysema  from  the  exercise  of  their  profes- 
sion. Of  this  latter  fact  I  am  certain — it  is  not  the  due  use, 
not  the  "straining"  of  the  pulmonary  membrane  which  causes 
it  to  degenerate,  but  rather  the  want  of  use.  In  this  respect  it 
resembles  all  other  livino;  animal  tissues. 


EMPHYSEMA  OF  THE  LUNGS.  281 

-     {Clinical,  St.  Marys,  March  21,  1863.) 

I  will  t^ke  the  opportunity  of  having  admitted,  a  week  ago, 
two  cases  of  pulmonary  emphysema,  to  recur  to  our  subject  of  a 
recent  lecture. 

John  D.  is  a  poor  street-sweeper  now,  and  nearly  seventy 
years  old,  but  has  been  a  gentleman's  servant,  has  had  "his  beer 
regular,"  and  taken  it  freely.  This  confession  is  corroborated 
by  the  shaking  of  his  hands  when  he  puts  them  up.  lie  says 
he  has  been  "queer  and  wheezy"  and  subject  to  frequent  coughs 
for  six  years,  and  five  years  ago  was  under  my  care  for  asthenic 
gout.  The  cough  is  of  a  violent  spasmodic  character,  and  does 
not  bring  up  much  mucus.  His  chest  is  resonant  and  rounded, 
and  moves  very  little  on  inspiration.  The  cardiac  dullness  com- 
mences at  a  low  level  at  the  base  of  the  heart,  and  the  pulsations 
of  the  organ  are  felt  in  the  epigastrium.  His  corpulence  pre- 
vents us  from  getting  the  auscultatory  signs  of  emphysema  so 
clearly  marked  as  one  would  wish.  There  is  not  now,  nor  does 
there  ever  appear  to  have  been,  any  anasarca. 

The  urine  is  albuminous,  of  the  specific  gravity  1-012 

In  this  case  I  think  there  is  a  generally  distributed  deficiency 
of  elasticity  in  the  pulmonary  tissue,  which  has  arisen  from  the 
same  diathesis  as  the  morbid  state  of  his  kidneys  (shown  by  the 
albumen  in  the  urine)  and  perhaps  of  other  organs  as  well. 
But  his  general  weak  health,  graphically  described  by  him  as 
"queer,"  has  prevented  his  working  hard,  though  I  dare  say  he 
has  lived  hard  and  drunk  hard ;  and  in  consequence  the  deter- 
mining cause  which  I  explained  to  you  fully  in  my  lecture  a 
fortnight  ago,  of  forced  and  impeded  expiration,  has  not  been 
present.  Thus  local  spots  of  very  marked  emphysema  are  not 
found.  The  defective  vitality  of  the  renal  tissue,  which  makes 
him  an  albuminuriac,  is  doubtless  of  the  same  nature  as  that  in 
the  lungs ;  and  it  causes  a  tendency  in  the  blood  to  throw  out  its 
serum  and  thus  to  saturate  the  lungs  with  fluid,  which  assists 
also  in  concealing  from  our  ears  the  signs  of  the  emphysema 
present. 


282  EMPHYSEMA  OF  THE  LUNGS. 

The  prognosis  is  certainly  favorable  as  far  as  his  chest  is 
concerned,  but  I  fear  we  cannot  make  a  young  man  of  him. 

The  other  case  I  will  read  from  the  case-book. 

"  George  H.,  aged  fifty-three,  a  plasterer,  first  became  asth- 
matic two  years  and  a  half  ago.  After  suffering  a  few  weeks 
and  expectorating  a  little  mucus  streaked  with  blood,  he  was 
admitted  into  the  hospital  under  Dr.  Sibson,  and  remained  six 
weeks,  having  during  that  period  had  a  carbuncle  on  his  neck 
and  an  abscess  in  the  left  axilla.  He  Avent  out  relieved,  and 
has  been  able  to  work  ever  since,  in  spite  of  his  asthma,  till  a 
month  before  last  Christmas,  Avhen  he  again  was  obliged  to  give 
up.  On  his  coming  under  my  charge,  March  20,  he  presented 
the  usual  marked  signs  of  extensive  emphysema  of  the  lungs. 
His  chest  is  rounded,  and  the  lower  angles  of  the  scapula  are 
thrown  upwards  and  onwards.  The  left  side  of  the  thorax  is 
larger  and  more  rounded  than  the  right.  There  is  very  marked 
resonance  all  over  it,  including  the  cardiac  region,  and  the  heart 
is  pressed  downwards,  pulsating  regularly  in  the  epigastrium  ; 
the  valve  sounds  are  healthy.  The  breathing  is  abdominal ;  the 
respirations  are  twenty-eight  in  a  minute.  The  face  is  livid, 
and  the  lips  blue,  but  without  any  of  that  bloated  appearance  so 
common  in  asthma  from  diseased  heart.  There  is  a  good  deal 
of  frothy  expectoration,  but  no  blood  streaks  in  it.  The  urine 
is  healthy." 

While  examining  before  you  this  and  some  other  emphyse- 
matous chests,  I  have  been  asked  by  pupils  how  it  is  that  iliere 
is  no  bulging  of  the  intercostal  spaces,  and  I  have  been  ^iven  to 
understand  that  bulging  of  the  intercostal  spaces  is  taught  as  a 
sign  of  emphysema.  This  is  an  error — the  intercostal  spaces 
do  not  "bulge,"  like  as  when  the  pleurae  are  full  of  fluid,  a  fact 
which  you  may  ascertain  for  yourselves  now.  But  of  c^mrse 
from  the  chest  being  always  in  a  state  of  fullness,  the  ribs  are 
widely  separated  from  one  another.  This,  however,  is  a  very 
different  thing  from  intercostal  bulging,  as  you  may  see  in  both 
the  dead  and  living  body. 

I  have  ascertained,  by  a  reference  to  Dr.  Sibson's  case-book, 
that   the  signs   and  symptoms   exhibited   by  this  patient  were 


EMPHYSEMA  OF  THE  LUNGS.  283 

much  the  same  on  his  former  admission  as  they  are  now.  He 
is  not  essentially  worse,  and  indeed  his  trade  is  not  one  which 
with  ordinary  care  and  prudence  would  be  an  injurious  one. 
The  prognosis  therefore  may  be  considered  favorable. 

I  will  view  as  one  the  treatment  of  these  two  persons,  inasmuch 
as  I  have  ordered  them  both  the  same  draughts,  viz. : — 

I^    Tinct.  ferri  sesquichloridi  11\xx, 
Tinct.  lohelise  setherese  "rtlxv, 
e  Mist,  campliorse  .^j, 
ter  die. 

The  object  of  the  iron  is  to  try  and  restore  its  full  vital 
powers  to  the  creative  arterial  blood,  so  that  it  may  renew  the 
pulmonary  membrane,  that  it  may  form  healthy  elastic  tissue, 
instead  of  the  degenerated  and  imperfectly  elastic  tissue.  That 
places  where  the  walls  of  the  air-vesicles  are  broken  away,  and 
Avhere  bullae  exist  instead  of  vesicles,  should  be  filled  up  again 
with  a  new  growth,  may  be  considered  beyond  hope  ;  but  that 
where  the  form  of  the  lung  substance  remains  perfect,  where  to 
the  naked  eye  it  is  intact,  and  only  under  the  microscope  ex- 
hibits its  incipient  death,  there  I  believe  we  need  not  despair  of 
our  restorative  agent  having  a  fair  chance  of  success.  The 
best  restorative  medicine  is  the  healthy  blood  of  the  patient's  own 
body,  and  to  make  that  blood  healthy  is  the  most  rational  aim 
we  can  have. 

To  the  iron  I  shall  at  a  future  day  add,  in  the  case  of  George 
H.,  cod-liver  oil,  as  a  means  of  affording  a  molecular  base  to 
the  growth  of  new  tissue.  He  is  thin,  as  you  see,  and  it  will 
be  readily  absorbed  by  the  intestines,  and  probably  agree  well 
with  him.  I  feel  more  doubtful  about  oil  in  the  case  of  John 
D.,  as  he  is  so  flabbily  corpulent ;  but  I  shall  try  cautiously  how 
he  beirs  it. 

You  may  have  remarked  that  I  refused  the  very  urgent  request 
of  John  D.  for  beer,  which  he  said  habit  had  made  a  necessary 
for  him.  I  hope,  if  possible,  to  break  him  of  the  habit,  for 
nothing  is  so  injurious  to  degenerative  tendencies  as  alcohol,  and 
no  form  of  alcoholic  liquid  so  bad  as  beer. 


284  EMPHYSEMA  OF  THE  LUNGS. 

No — I  must  make  one  exception  to  the  bad  pre-eminence  of 
alcohol,  that  is,  mercury.  Avoid  mercury  in  these  cases  as  you 
would  a  poison.     Avoid  also  purgatives. 

The  lobelia  is  ordered  as  a  substitute  for  a  more  powerful 
medicinal  agent,  tobacco.  Nothing  calms  the  distressing  asthma 
so  well  as  a  few  whiffs  of  strong  Virginia.  But  to  allow  smoking 
in  the  hospital  would  lead  to  breaches  of  discipline ;  so  I  order 
that  which  is  apparently  the  next  best  thing.  Like  tobacco, 
lobelia  is  a  very  variable  article ;  there  seems  to  be  as  much 
difference  between  one  specimen  and  another,  as  between  the 
mildest  cigarette  and  the  strongest  shag.  This  accounts  for 
Avhat  we  read  of  enormous  doses  being  sometimes  perfectly  inert, 
and  of  much  less  quantities  having  acted  as  a  poison.  A  further 
safety  to  those  who  have  taken  large  doses  lies  in  the  fact  of  its 
being  like  tobacco,  an  emetic,  and  so  freeing  the  stomach  of  its 
presence  in  excess.  I  should  advise  you  to  use  the  strongest 
sort,  paying  the  best  price  at  the  best  shop,  so  that  you  may  give 
it  in  moderate  and  graduated  doses.  Lobelia  does  not  disagree 
with  the  digestion  like  opium,  and  you  need  not  on  that  score 
abstain  from  its  use. 

Another  agent  of  the  same  character  as  tobacco  is  stramo- 
nium. It  also  is  best  administered  in  a  pipe,  but  here  again  the 
hospital  discipline  interferes,  and  I  am  obliged  to  give  it  him  in 
pills  made  Avith  the  extract,  which  you  may  see  are  not  so  effi- 
cient in  this  instance  as  the  lobelia,  though  in  the  form  of  smoke 
it  is  often  more  useful. 

Perhaps  some  of  you  may  doubt  whether  it  is  quite  wise  to 
diminish  by  calmatives  the  action  of  the  respiratory  function, 
and  may  think  the  asthma  an  effort  of  nature,  ordained  to 
accompany  emphysema  for  a  beneficial  purpose.  This  is  a  case 
in  point  very  subversive  of  the  theory  of  disease  being  an  "  effort 
of  nature."  The  forced  breathing,  nay,  even  the  natural  breath- 
ing, tends  to  dilate  the  vesicles,  and  if  it  were  designed  to  ben- 
efit the  patient,  we  should  have  to  conclude  that  the  design  was 
erroneous — a  conclusion  repugnant  to  instinctive  reverence. 

When  there  is  an  unhealthy  condition  of  the  mucous  mem- 
brane of  the   trachea   and   laige  bronchi,   evinced   by  copious 


EMPHYSEMA  OF  THE  LUNGS.  285 

expectoration,  3^011  will  find  benefit  from  cantliarides  or  turpen- 
tine, either  administered  by  the  mouth,  or  applied  to  the  surface 
of  the  chest  in  the  form  of  blisters  and  rubefacient  embrocations. 
These  drugs  often  act  very  powerfully  as  restoratives  of  healthy 
action  to  diseased  mucous  membranes.  They  indirectly  in  this 
way  benefit  the  emphysematous  lung,  by  preventing  the  neces- 
sity for  so  much  coughing ;  but  they  are  not  directly  useful  to 
the  tissue  mainly  at  fault. 

I  do  not  approve  of  the  use  of  squill  or  ipecacuanha,  and  still 
less  of  antimony.  Even  if  they  appear  to  relieve  for  the  moment, 
which  is  by  no  means  generally  the  case,  yet  they  lower  the 
appetite  and  the  powers  of  digestion,  and  thus  stand  in  the  way 
of  active  restorative  treatment  in  emphysema. 


{Clinical,  St.  Marys,  October  31,  1864.) 

There  have  been  under  your  eyes  during  the  month,  two  cases 
very  graphically  illustrative  of  the  pathology  of  emphysema. 

On  October  7  there  was  received  from  the  Servant's  Home 
(where  she  had  been  living,  while  attending  as  an  out-patient), 
Annie  C,  aged  seventeen,  a  fat  but  stunted  maid-of-all-work. 
She  was  in  the  hospital  during  the  summer  of  last  year,  and 
I  find  that  her  illness  then  was  a  typh-fever,  slight  in  itself,  but 
which  had  come  on  during  a  wet  and  cold  foot-journey  from 
Norfolk,  and  which  had,  under  the  adverse  circumstances  of 
its  supervention,  caused  pneumonia  of  the  lower  lobes.  She 
recovered  perfectly  to  all  appearance  both  the  use  of  her  lungs 
and  her  flesh  at  that  time.  But  yet  she  says  she  has  never 
quite  ceased  to  suffer  from  shortness  of  breath.  This  shortness 
of  breath  has  been  gradually  growing  upon  her,  and  prevents 
her  keeping  any  place  as  a  domestic  servant.  On  admission  she 
was  very  blue  in  the  lips  and  face,  and  was  suffering  great  dys- 
pnoea ;  the  respirations  being  forty  in  the  minute.  She  said  she 
had  not  been  able  to  lie  down  in  bed  for  two  months.  There 
were  loud  snoring  and  cooing  rales  throughout  the  lungs,  inter- 
spersed with  occasional  cracklings  in  various  parts,  a  roundness 
19 


286  EMPHYSEMA  OF  THE  LUNGS. 

of  the  thoracic  walls,  abdominal  and  heaving  i-espiration,  and 
resonance  on  percussion  noore  extensive  in  every  direction  than 
it  ought  to  be.  The  heart,  however,  is  not  entirely  overlapped 
by  the  lung,  so  that  this  evidence  of  local  emphysema  in  the 
left  lung  is  not  complete.     The  cardiac  sounds  are  healthy. 

Emphysema  is  not  usual  in  girls  of  seventeen,  and  we  are  able 
therefore  the  more  distinctly  to  refer  this  case  to  the  peculiar 
adverse  circumstances  in  which  she  had  been  placed.  Conges- 
tive inflammation  of  the  pulmonary  substance  had  been  induced 
by  exposure  in  a  person  previously  disposed  to  it  by  the  typhous 
state.  The  congestion  had  been  relieved  by  treatment,  but  there 
was  left  behind  the  weakened  life  of  the  tissue  unable  completely 
to  recover  itself.  This  has  resulted  in  gradual  local  degenera- 
tion ;  in  spite  of  the  patient's  generally  well  nourished  condition, 
her  lungs  are  starved  and  emaciated. 

This  is  the  reason  why  I  have  treated  her  with  iron  and  qui- 
nine, in  addition  to  the  gethereal  tincture  of  lobelia,  which  was 
given  to  alleviate  the  special  symptoms  at  first.  She  is  now  able 
to  breathe  easier  and  to  lie  down  in  bed,  but  I  am  afraid  she 
must  be  turned  adrift  on  the  cold  world  next  week,  for  one  can 
hardly  expect  to  fit  her  for  domestic  service,  and  more  pressing 
cases  demand  the  use  of  our  beds. 

Bridget  G.,  an  unmarried  Irish  servant-girl,  aged  twenty-five, 
was  admitted  on  the  19th.  She  has  the  same  sturdy  build  and 
bloated  look  as  the  last  patient,  and  I  cannot  help  thinking  that 
most  probably  the  pathological  history  of  her  case  is  the  same. 
It  is  true  that  we  cannot  draw  from  her  any  account  of  pneu- 
monia ;  but  she  is  impenetrably  stupid  and  ignorant,  and  hardly 
understands  the  English  language,  so  that  I  do  not  reckon  her 
answers  to  cross-questions  as  of  much  worth.  She  might  easily 
have  had  slight  pneumonia  without  recording  in  her  memory  any- 
thing which  could  lead  us  to  a  knowledge  of  it.  Even  in  the 
former  case,  I  doubt  if  the  clinical  clerk  would  have  made  out 
the  occurrence  of  pneumonia  and  typh-fever  from  the  girl's  tale 
without  the  aid  of  our  former  notes. 

Bridget's  symptoms  have  been  coming  on  three  years,  and  in 
consequence  the  lungs  occupy  a  larger  space  than  Annie  C.'s, 


EMPHYSEMA  OF  THE  LUNGS.  287 

overlapping  the  heart  and  rendering  the  cardiac  region  resonant. 
Her  degree  of  dyspnoea,  however,  is  not  so  great,  nor  is  the 
impediment  to  lying  down  flat  so  marked.  I  have  often  re- 
marked that  the  asthmatic  symptoms  of  emphysema  are  by  no 
means  proportioned  to  the  large  extent  of  the  parts  affected ; 
their  severity  rather  depends  on  the  rapidity  with  which  the  de- 
generation is  advancing. 

1  have  put  her  on  a  course  of  iron,  for  which  I  have  already 
to-day  told  you  my  reasons. 

I  have  also  had  her  cupped  between  the  shoulders,  as  an  ex- 
pedient of  immediate,  though  temporary,  relief;  and  an  expedient 
Avhich  the  prominence  of  the  venous  crasis  amply  justifies  in  her 
case ; — she  Avill  soon  recover  the  blood  lost. 

She  had  been  taking,  by  somebody's  orders,  some  pills  of  squill 
and  ipecacuanha  every  night.  I  continued  them,  in  order  to  ob- 
serve their  influence.  On  leaving  them  off  she  slept  quite  as  easy 
as  when  taking  them  (she  said  "easier"),  and  I  could  detect  no 
change  in  the  quantity  or  quality  of  the  sputa.  So  that  expec- 
torants are  evidently  of  no  use,  an  observation  I  have  often  had 
occasion  to  make  in  cases  of  emphysema. 

You  have  fairly  exhibited  in  the  history  of  these  two  girls  the 
slow  and  gradual  march  of  a  degenerative  lesion  as  a  local 
affection  in  a  sanguine  and  otherwise  healthy  person.  You  see 
it  caused  by  privations  and  injuries,  rather  than  by  any  violent 
special  exertion  of  the  part.  And  you  see  how  these  causes  act 
even  in  persons  not  constitutionally  liable  to  such  degeneration, 
namely,  with  great  slowness  and  without  threatening  any  immi- 
nent danger.  It  is  different  with  leuco-phlegmatic  persons.  In 
their  case  the  advance  of  degeneration  is  repaid  and  acute,  and, 
if  not  checked  by  active  tonic  treatment,  proceeds  soon  to  its 
fatal  termination. 

You  will  say  this  is  a  great  advantage  for  persons  of  sanguine 
temperament.  So  it  is.  But  it  has  its  counter-balance.  De- 
generation in  them  is  much  less  amenable  to  treatment,  especially 
to  treatment  by  iron,  which  is  the  most  valuable,  than  it  is  in  the 
leuco-phlegmatic.  Though  rarer  and  slower,  its  march  in  them 
is  unfortunately  sjircr,  when  it  has  once  begun. 


LECTURE   XXIII. 

PULMONARY   CONSUMPTION. 

Pathological  data  concerniny  phtJdsis — TJie  disease  localized  by 
morbid  anatomy  and  auscultation — Pitfalls  incident  to  this 
knowledge — Not  the  presence,  but  the  increase,  of  tubercle, 
is  the  chief  imint — Innocuousness  of  non-2)rogressive  tubercle 
— Object' of  treatment  should  be  the  organs  of  nutrition, 
not  those  of  respiration — Food — Cough  medicines — Ajjpetite 
— Iron — Cod-liver  oil — Alcohol — Remedies  for  diarrhoea — 
Cachetic  phthisis  —  Chlorate  of  potash  —  Delirium  hi  the 
last  stage  of  phthisis,  hoiv  caused,  and  how  to  be  treated — 
Specifics. 

{Clinical,  St.  Mary's,  December  13,  1861.) 

I  SHALL  not  to-day  detail  any  particular  instance's  of  pulmo- 
nary consumption.  For  there  always  are  several  in  the  wards, 
to  which  I  have  called  your  attention  on  points  of  diagnosis  ; 
and  it  would  he  wasting  the  valuable  time  of  a  clinical  lec- 
ture to  recite  their  familiar,  phenomena ;  which,  so  far  as  they 
affect  the  treatment,  are  very  uniform,  and  perfectly  familiar  to 
you. 

I  take  it  for  granted  also  that  in  the  systematic  course  of  lec- 
tures on  medicine  you  have  assented  to  the  following  propositions, 
which  seem  to  me  to  comprise  the  chief  points  contributed  by 
pathology  towards  the  treatment  of  the  disease,  and  in  proving 
which  a  great  deal  of  time  and  thought  have  been  worthily  spent. 
I  shall  assume — 

1.  That  the  cause  of  the  symptoms,  of  the  disease,  of  its  fatal- 
ity in  fatal  cases,  is  the  occupation  by  tubercle  of  vital  organs, 
especially  the  lungs ; — 


PULMONARY  CONSUMPTION.  289 

2.  That  the  tendency  to  the  formation  of  tubercle  resides  in 
the  constitution  of  the  individual; — 

3.  That  this  tendency  may  be  either  hereditary  or  acquired, 
or  both  hereditary  and  acquired  at  once ; — 

4.  That  the  circumstances  which  quickest  develop  this  ten- 
dency are  the  same  as  contribute  to  anaemia,  namely,  starvation, 
bad  air,  deprivation  of  light,  exposure  to  cold  without  power  of 
resistance,  fatigue,  previous  illness,  in  short,  all  depressants  of 
the  powers  of  life  by  want  of  supply  to  the  formation  of  tissue. 

Anatomy  and  auscultation  have  rendered  us  the  enormous 
service  of  tracing  out  truly  in  death  and  life  the  organs  chiefly 
injured  in  pulmonary  consumption,  and  the  nature  of  the  injury 
done.  What  an  incalculable  advantage  we  have  over  our  grand- 
fathers in  this  respect !  What  a  contrast  between  the  dangerous 
confusion  of  various  diseases  under  one  head,  the  distinctions 
without  differences  spoken  of  in  the  writings  of  the  bygone  age. 
and  the  almost  pedantic  precision  of  our  diagnosis !  But  do  not 
stop  here;  pathology  must  carry  you  on  further,  or  you  will 
have  gained  so  little  from  science,  that  I  doubt  if  your  practice 
will  be  any  better  than  your  grandfathers',  in  spite  of  the 
treasure  of  additional  knowledge  you  possess.  Often,  during 
our  talks  up  stairs,  I  perceive  signs  of  your  considering  the 
tubercle  as  "the  disease"  against  which  you  have  to  direct  the 
energies  of  your  minds,  and  from  which  the  patient  has  to  be 
rescued.  You  want  to  do  something  to  "stop"  it,  to  "absorb" 
it,  to  "counter-irritate"  or  "evacuate"  it;  you  seem  to  imagine 
that  if  you  could  take  away  that  mass  of  cheesy  matter  which 
auscultation  puts  almost  as  clearly  before  your  mind  as  if  the  ribs 
were  transparent,  your  treatment  would  be  perfect. 

And  I  fear  that  in  this  you  might  be  upheld  very  often  by 
the  tone  of  medical  literature,  even  of  modern  date.  For  exam- 
ple, I  read  in  the  "Cyclopsedia  of  Practical  Medicine"  that 
emetics  are  useful  in  the  early  stages  of  phthisis,  by  displacing 
and  evacuating  the  tubercles  from  the  lungs.  Can  the  writer 
ever  have  really  tried  with  a  scalpel  to  pick  out  a  tubercle  from 
the  pulmonary  tissue,  when  he  thus  suggests  the  possibility  of 
the  gentle  pressure  of  vomiting  effecting  such  a  feat?     And  I 


290  PULMONARY  CONSUMPTION. 

find  the  effects  of  cod-liver  oil  sometimes  attributed,  not  with 
obvious  common  sense  to  its  being  an  easily  digestible  oil,  but 
to  the  minute  traces  of  iodine  which  it  contains.  Yea,  iodine 
itself  has  been  given  in  long  courses  with  the  idea  of  bringing 
about  the  removal  of  the  tubercles. 

I  wish  to  put  these  notions  out  of  your  heads.  What  the 
patient  has  to  fear,  is  not  the  remaining  of  the  tubercle  in  the 
body,  but  its  increase.  That  which  is  once  there  has  done  its 
mischief,  its  path  of  ruin  is  past,  the  portion  of  lung  which  it 
has  occupied  is  gone  for  ever,  and  cannot  grow  again  any  more 
than  an  amputated  leg.  The  dissections  of  consumptives  almost 
always  show  the  cause  of  death  to  be  a  fresh  formation  of  tuber- 
cle at  no  distant  period,  which  has  abridged  the  remaining  organ 
to  a  degree  inconsistent  with  life.  A  single  deposit  of  tubercle 
to  a  moderate  extent  can  almost  always  be  recovered  from.  It 
is  the  continuous  repetition  of  the  morbid  process  which  is  so 
fatal. 

I  cannot,  therefore,  too  strongly  impress  upon  you,  that  riot 
so  much  the  tubercle  as  the  tendency  to  form  tubercle,  not  the 
morbid  matter  but  the  diathesis,  is  that  which  should  occupy 
your  thoughts. 

When  tubercle  first  takes  its  place  in  the  pulmonary  tissue, 
the  lung  feels  a  good  deal  inconvenienced  by  its  presence;  there 
is  cough,  inflammation  round  the  foreign  body,  and  condensation 
of  the  neighboring  substance ;  and  this  is  accompanied  by  general 
ill  health,  arising  from  the  sudden  loss  of  part  of  the  respiratory 
function,  to  which  loss  the  system  has  not  had  time  to  become 
accustomed.  These  consequences  are  directly  proportioned  to 
the  quantity  of  lung  spoilt.  They  may  be  so  severe  as  to  cause 
death  by  what  is  called  "tuberculous  pneumonia,"  or  by  "gal- 
loping consumption,"  "when  a  large  extent  of  lung  is  very  quickly 
rendered  unserviceable.  Or,  when  the  injury  is  more  gradual 
and  slighter,  they  may  be  so  insignificant  as  not  to  have  attracted 
notice  at  all.  The  other  day  in  a  patient  of  mine  who  died  of 
chorea  dependent  on  a  tubercle  in  the  spinal  cord,  you  saw  at 
the  post-mortem  examination  scattered  tubercles  in  both  lungs 
which  had  caused  no  symptoms  at  all  during  life,  though  they 


PULMONARY  CONSUMPTION.  291 

probably  had  been  there  much  longer  than  the  tubercle  in  the 
less  usual  situation  which  proved  fatal.  And  very  often  in  per- 
sons killed  by  accident,  apparently  in  the  prime  of  activity  and 
with  no  history  of  any  serious  illness,  you  find  crude  tubercles, 
scars  of  former  tubercles,  and  the  chalk-like  debris  of  tubercular 
matter.* 

Passing  on  to  more  agreeable  evidence — we  find  people  with 
a  very  large  quantity  of  tubercle  in  the  lungs,  so  large  as  to 
have  almost  proved  fatal,  who  yet  recover  to  a  great  extent 
from  the  mischief  which  it  has  caused.  When  once  the  lung 
has  got  over  the  shock  produced  by  the  presence  of  the  first 
load  of  dead  matter,  the  health  recovers,  and  the  patient  (though 
imperfect  in  body  of  course)  has  only  to  fear  a  fresh  crop.  It 
is  astonishing  what  enormous  ravages  may  be  made  in  the  lung, 
and  yet  with  the  help  of  what  remains  how  people  will  recover 
the  health  that  has  been  lost.  I  dare  say  you  may  remember 
last  summer  a  poor  old  woman  sent  to  the  hospital  to  die.  There 
was  in  the  left  upper .  lobe  a  vomica,  so  large  that  there  was 
"metallic  tinkling"  in  it;  and  for  some  weeks  I  took  the  oppor- 
tunity thus  afforded  of  teaching  you  this  sound.  You  know  from 
my  lectures  on  diagnosis  that  it  hardly  ever  occurs  except  in 
pneumothorax  with  perforation,  and  not  always  there;  that  it  is 
very  rare  in  vomicse,  and  when  present  indicates  a  cavity  bigger 
than  your  fist  at  least.  So  weakened  was  the  patient  by  tl>e 
loss  of  so  much  lung,  that  she  was  at  first  unable  even  to  feed 
herself,  and  quite  soaked  the  bed  with  colliquative  perspirations. 
Yet,  contrary  to  all  our  expectations,  she  lost  her  night  sweats, 
gained  flesh,  walked  about  the  ward,  and  finally  walked  off  home 
during  my  absence  from  London,  so  that  I  cannot  say  what  was 
the  exact  state  of  her  chest  on  leaving.  But  I  will  take  for 
granted  that  the  cavity  remained  unclosed,  and  probably  will 
remain  unclosed  for  the  rest  of  her  life. 

*  In  566  autopsies  of  tubercular  persons,  which  I  found  recorded  in  the  poat- 
morlem  books  of  St.  George's  Hospitul  during  ten  years,  there  was  seen  the  so- 
called  "cretaceous"  matter  in  the  pulmonar}' tissue  in  65.  See  "  Decennium 
Pathologicum/'  cliap.  v,  sect.  7,  where  statistical  arguments  are  assigned  for 
considering  this  solid  substance  to  be  really  of  tubercular  character. 


292  PULMONARY  CONSUMPTION. 

I  say  I  take  for  granted  that  the  cavity  Avill  remain  unclosed 
for  the  rest  of  her  life,  from  my  experience  of  post-mortem  ex- 
{iminations,  which  lead  to  the  conclusion,  that  in  cases  of  cured 
phthisis  pulmonalis  vomicas  rarely  heal  up,  hut  that  they  hecome 
dormant  and  comparatively  innocent,  lined  with  a  thick  mem- 
hrane,  and  thus  separated  from  the  healthy  lung  around  them.* 

I  can  give  also  other  and  living  evidence. — For  example,  R. 
S.,  a  wine  merchant,  aged  forty-two,  was,  in  1846,  under  the 
care  of  several  of  the  most  experienced  in  chest  complaints  of 
the  London  physicians.  He  had  a  large  vomica  in  the  left  apex, 
was  excessively  debilitated  by  it,  and  was  sent  home  with  the 
information  that  he  could  not  live  a  month.  Well,  he  picked  up 
strength  and  flesh,  was  enabled  to  return  to  his  business,  and, 
when  I  saw  him  in  1858,  twelve  years  afterwards,  he  was  in  fair 
health,  and  as  able  to  do  a  moderate  day's  work  as  anybody  I 
know;  but  auscultation  left  no  doubt  that  the  vomica  was  still 
open  in  the  lung,  and  that  the  small  quantity  of  pus  he  expecto- 
rated came  from  it. 

In  1855,  I  advised  a  young  man,  with  softening  tubercles  in 
the  left  lung,  to  accept  a  chance  which  he  had  of  settling  in  the 
West  Indies.  Six  and  a  half  years  afterwards,  he  returned  to 
England  for  a  temporary  purpose,  and  came  to  me  about  some 
sjmptoms  not  connected  with  his  chest.  I  found  that  his  vomica 
Tifas  still  there,  and  secreting  pus;  but  that  he  had  never  per- 
manently lost  again  the  flesh  which  a  course  of  iron  and  cod-oil 
had  put  upon  him.  He  had  even  had  an  attack  of  haemoptysis, 
and  gone  through  yellow  fever,  without  serious  injury. 

As  a  contrast  to  such  cases — and  the  way  in  which  we  lose 
sight  of  our  patients  prevents  our  multiplying  them — as  a  con- 
trast to  these  where  vomicas  have  become  innocuous,  compare 
those  in  which  chronic  consumption  proves  fatal.  In  the  latter, 
a  dissection  always  (accidental  cases  excepted)  reveals,  either  in 
the  lungs  themselves  or  in  other  vital  organs,  a  formation  of 

*  Reasons  are  given  in  the  chapter  cited  in  the  last  note  from  my  "  Decenniura 
Pathologicum,"  in  the  Medico-Chirurgical  library,  for  believing  that  "chalky 
masses''  in  the  pulmonary  tissue  are  not  the  remains  of  Tomici«  but  of  hard 
tubercle,  which  has  dried  up  without  softening. 


PULMONARY  CONSUMPTION.  293 

fresh  hard  tubercle  as  the  cause  of  death,  besides  the  established 
vomica  or  the  old  masses  of  morbid  matter. 

It  is  clear,  therefore,  that  it  is  the  tendency  to  tubercle,  and 
not  the  existing  tubercle,  which  we  have  to  fear  and  to  guard 
against;  and  that  for  the  successful  treatment  of  consumption 
we  must  withdraw  our  minds  from  the  morbid  anatomy  of  the 
locality  to  the  fatal  propensity  of  the  constitution. 

To  my  mind,  it  is  a  great  relief  and  rest  to  be  able  to  map  out 
by  auscultation  the  exact  extent  of  the  mischief  done,  and  to 
know  that  there  is  enough  of  the  morbid  change  discovered  to 
account  for  the  severity  of  the  symptoms.  I  feel  then  like  a 
general  who  is  acquainted  with  the  exact  position  and  whole  force 
of  his  enemies,  and  is  sure  that  the  country  will  suffer  no  further 
loss  if  they  can  only  be  kept  from  advancing. 

In  the  case  of  chronic  consumption  hope  should  never  be  en- 
tirely lost.  If  the  remaining  portion  of  lung  has  retained  life 
so  long,  it  can  retain  life  longer,  and  the  whole  attention  can  be 
applied  to  its  conservation.  There  is  no  question  about  the  future 
conduct  of  the  war,  if  only  reinforcements  for  the  enemy  can  be 
stopped  in  their  march. 

To  what  quarter  must  we  look  for  aid  in  this  conservation  ? 
I  know  you  are  disposed  to  turn  first  to  the  lungs.  But  if  we 
inquire  into  the  histories  of  those  who  have  lived  long  with 
vomicae  or  tubercles,  they  are  by  no  means  found  to  have  taken 
special  care  of  their  chests — they  have  not  coddled  or  lived  in- 
doors in  even  temperatures,  hanging  their  lives  on  to  their  ther- 
mometers for  fear  of  coughs :  they  have  gone  on  with  their 
professions  or  business  or  work  :  they  have  not  "  laid  a  knife  to 
their  throat,"  but  have  eaten  and  drunk  like  other  people,  and 
have  enjoyed  the  gratification  of  their  appetites.  A  patient  of 
mine,  over  fifty,  with  copious  pyoptysis  and  condensed  lungs 
(of  probably  a  tubercular  nature)  from  his  youth,  has  kept 
hounds,  broken  his  bones  like  other  Nimrods,  contested  county 
elections,  sat  in  parliament,  enjoyed  his  champagne  and  other 
good  things,  but  7iever  allows  any  doctering  of  his  chest. 

Nor  is  it  only  when  tubercle  is  established  that  it  may  be 
arrested  hj  exposure  of  the  body  to  active  change;  even  the 


294  PULMONARY  CONSUMPTION. 

tendency  may  be  averted.  I  examined  for  insurance,  a  few 
weeks  back,  a  gentleman  aged  fifty-five,  the  second  of  a  family 
of  eleven  in  whom  phthisis  was  hereditary.  Circumstances  have 
caused  the  three  eldest  to  rough  it  in  the  world:  they  have 
traveled  and  worked  for  their  bread,  and  now,  when  wealthy, 
they  are  healthy,  active  sportsmen.  The  seven  youngest  were 
coddled  and  petted,  and  all  died  of  consumption  under  twenty- 
five. 

The  statistics  of  death  by  phthisis  in  the  two  sexes  corrobo- 
rate this  deduction.  Although  males  arc  more  liable  to  tuber- 
culosis than  females,  yet  they  are  less  liable  to  have  that 
tuberculosis  exhibited  in  the  lungs.  (See  "  Decennium  Patho- 
logicum,"  chap,  iv.)  Now  in  all  classes  of  social  life,  women 
are  the  least  disposed  to  exert  and  expose  their  lungs ;  they  are 
more  ready  to  invalid  themselves ;  and  in  the  lower  classes, 
whence  these  statistics  are  taken,  they  do  not  wear  low  dresses 
or  tight  stays  (to  which  habits  some  have  attributed  consump- 
tion). Yet  we  find  that  tubercle  with  them  takes  the  direction 
of  the  spared  organ. 

You  may  perhaps  say,  "This  spared  organ  is  a  most  import- 
ant one :  I  will  sacrifice  the  others  to  the  possible  chance  of 
saving  it."  But  consider — what  is  this  tubercular  matter?  It  is 
not  anything  peculiar  to  the  lungs,  but  may  arise  from  degene- 
rated nutrition — the  inferior  development  of  life — of  any  part, 
and  may  occur  in  any  part.  Now,  excepting  my  glands,  many 
of  which  I  could  easily  spare,  I  should  prefer  having  it  in  my 
lungs  to  any  other  part  of  my  body  ;  for  I  know  that  I  can  live 
with  a  good  deal  less  pulmonary  tissue  than  nature  has  given 
me.  But  I  cannot  live  with  an  equal  amount  of  deficiency  in 
my  brain,  or  my  heart,  or  my  alimentary  canal,  of  which  I  have 
onlv  one.  So  that  if  tubercle  is  to  exist  at  all,  I  really  do  not 
know  that  we  should  look  upon  it  as  a  misfortune  when  it  oc- 
curs in  the  chest,  as  it  is  safer  there  than  in  most  parts  of  the 
body. 

If  then  care  bestowed  upon  the  lungs  and  special  coddling  of 
them  increases  the  danger  of  tubercular  tendencies,  as  the  above 
arguments  clearly  show ;  and  if,  supposing  that  special  medica- 


PULMONARY  CONSUMPTION.  295 

tion  could  keep  tubercle  out  of  the  lungs  in  particular,  no  ad- 
vantage is  thus  gained — to  what  Avould  I  have  3'ou  turn? 

Leave  the  respiratory  organs  alone,  and  direct  your  thoughts 
to  the  organs  of  nutrition,  the  stomach  and  bowels,  which  will 
receive  with  thankfulness,  and  return  with  interest  any  care  you 
bestoAV  upon  them. 

It  is  truly  by  aid  of  the  digestive  viscera  alone  that  consump- 
tion can  be  curable.  Medicines  addressed  to  other  parts  may  be 
indirectly  useful  sometimes,  but  they  more  commonly  impede  the 
recovery  ;  whereas  aid  judiciously  given  in  this  quarter  is  always 
beneficial  and  usually  successful. 

The  chest  is  the  battle-field  of  past  conflict,  the  stomach  the 
ripening  ground  for  new  levies  of  life. 

Your  aim  should  be  to  get  the  greatest  possible  amount  of 
albuminous  food  fully  digested  and  applied  to  the  purpose  of 
the  renewal  of  the  body,  at  the  same  time  that  the  renewing 
agencies  are  brought  to  their  highest  state  of  efficiency.  In 
this  way  a  healthy  cell-renewal  takes  the  place  of  that  morbid 
imperfect  cell-renewal  which  appears  in  the  shape  of  tubercular 
matter. 

With  this  view  I  shun,  as  far  as  I  can,  all  those  "potent  herbs 
and  baneful  drugs"  which  may  be  classed  together  as  "cough 
medicines,"  meaning  antimony,  ipecacuanha,  and  squill  espe- 
cially. I  avoid  also  merjcury,  purgatives,  and  neutral  salts, 
Avhich  are  debilitants.  Where  the  heart  is  thin  and  weak, 
digitalis  is  sometimes  useful,  by  regulating  and  calming  its 
action;  but  as  a  rule  it  is  injurious,  by  reason  of  the  nausea  and 
loss  of  appetite  which  it  causes. 

The  appetite  should  be  the  great  object  of  your  care.  You 
will  often  find  it  sadly  wanting ;  and  where  that  happens,  the 
mucous  membrane  of  the  stomach  and  bowels  should  be  braced 
up  by  quinine  and  strychnine.  The  latter  acts  quickly,  and 
maybe  added  to  the  other  medicines  from  time  to  time;  but  the 
former  is  most  permanent  in  its  effects,  and  should  be  begun  at 
once,  and  continued  through  the  whole  process  of  medication, 
till  the  appetite  equals  or  exceeds  that  of  a  healthy  person. 

Iron,  again,  you  will  find  a  most  powerful  ally.     The  increase 


296  PULMONARY  CONSUMPTION. 

in  the  hajmatine  of  the  blood  which  follows  its  use  is  all-im- 
portant ;  for  thus  you  supply  to  the  tissues  the  true  life-giving 
medicine — red  blood.  Begin  iron  in  small  doses,  and  gradually 
increase  it  till  you  have  found  the  full  quantity  the  patient  can 
take,  and  then  continue  to  administer  rather  less  than  that,  so 
as  to  leave  room  for  an  occasional  augmentation  according  to 
circumstances.  Where  you  give  digitalis,  make  it  a  rule  to  add 
iron  and  sometimes  strychnine  to  the  dose,  as  you  thus  get  the 
full  advantage  of  the  digitalis,  and  shirk  some  of  its  possible 
evils.  Iron  prevents  nausea,  and  strychnine  co-operates  in 
strengthening  and  regulating  the  action  of  the  weakened  heart. 

When  the  repugnance  to  eating  is  extreme,  adopt  the  plan 
you  so  often  see  used  in  these  wards  with  success,  of  giving  milk 
in  small  and  very  frequently  repeated  doses.  Nutrition  has  a 
habit  like  that  of  arguinfj  in  a  circle;  food  creates  the  desire 
for  food — of  course,  by  strengthening  the  digestive  organs;  and 
thus,  after  a  few  days  of  milk  diet,  the  patients  will  voluntarily 
ask  for  meat,  and  enjoy  as  a  luxury  that  which  a  short  time 
before  excited  the  greatest  disgust.  If  you  find  the  milk  lie 
long  in  the  stomach  and  produce  heartburn  or  acid  eructations, 
add  lime-water  or  soda-water  to  it.  The  first  is  the  cheapest, 
the  latter  the  pleasantest. 

Cod-liver  oil  will  also  often,  like  milk,  create  an  appetite.  But 
as  a  rule,  especially  in  private  practice,  it  is  well  not  to  commence 
it  too  soon  ;•  for  the  nastiness  of  the  taste  and  feel  is  hard  to  get 
over  at  first,  and  it  is  much  easier  to  take  it  when  the  appetite 
has  begun  to  be  renewed.  Then  it  is  not  felt  as  a  hardship  even 
to  begin,  and  in  a  short  time  patients  will  get  really  to  like  it. 
And  they  Avill  like  it,  not  merely  as  reasonable  men  like  that 
which  does  them  good,  but  irrespectively  of  such  knowledge  th^y 
will  find  it  nice  to  the  palate.  Thus  children,  who  always  hate 
being  done  good  to,  will  still  often  take  to  their  oil  with  gusto. 
And  as  a  proof  that  exalted  reason  has  nothing  to  do  Avith  the 
preference,  the  same  thing  has  been  observed  in  brutes.  A 
clerical  friend  of  mine  had  a  consumptive  Skye  terrier,  which  he 
treated  secundem  artem  with  cod-liver  oil.  At  first  the  poor 
beastie  abhorred  it,  and  looked  sad  before  and  after  each  dose ; 


PULMONARY  CONSUMPTIOX.  297 

but  in  a  short  time  he  began  to  lick  his  lips  after  it,  and  if  he 
Avas  forgotten,  would  go  and  beg  more  canino  at  the  door  of  the 
cupboard  where  it  was  kept. 

The  best  sort  of  cod-oil  is  the  most  agreeable,  the  clearest,  the 
sweetest,  and  the  most  scentless — that,  in  fact,  which  is  tho- 
roughly free  from  extraneous  dirt.  The  oil  from  the  same  fish, 
formerly  used  by  curriers,  was  sold  for  their  use  cheap  and  foul, 
and  no  doubt  was  quite  good  enough  for  manufacturing  pur- 
poses; but  it  must  excite  a  very  natural  disgust  in  any  one  but 
an  Esquimaux  or  a  whaler,  I  should  think,  for  it  stinks  like  old 
train-oil.  Its  low  price  wholesale. allows  of  certain  firms  spending 
large  sums  in  widely  advertising  as  a  superior  form  of  drug;  but 
I  strongly  advise  you  never  to  prescribe  the  "brown  oil"  (as  the 
name  runs);  it  is  never  beneficial  where  the  pure  oil  fails,  and  it 
often  and  often  makes  the  patient  protest  he  will  on  no  consider- 
ation take  it  again.  The  mode  of  manufacture  which  causes  the 
difference  of  the  "brown"  and  "pale"  oil  is  described  in  an 
article  of  the  "Medico-Chirurgical  Review"  for  January,  1856, 
and  is  quite  enough  to  prevent  any  reader  of  delicate  perceptions 
ever  ordering  or  taking  it  again. 

The  best  plan  is  to  give  at  first  a  teaspoonful,  and  afterwards 
two  teaspoonfuls  thrice  a  day,  floating  on  the  quinine  or  iron 
mixture  to  which  the  patient  has  already  become  habituated.  I 
think  an  ounce  a  day  is  enough  to  administer  as  the  full  dose,  and 
need  not  be  exceeded.  If  the  patient  absorbs  all  that,  you  may 
be  quite  satisfied  ;  and  more  will  be  apt  to  turn  rancid,  and  cause 
indigestion,  the  worst  foe  of  the  phthisical.  The  best  time  to 
take  it  is  at  the  greatest  distance  from  meals,  as  thus  a  sort  of 
additional  meal  is  gained,  and  food  and  physic  are  not  confused ; 
but  if  your  patient  likes  any  other  time  better,  on  account  of 
taste  or  business,  do  not  stand  in  the  way  of  his  fancy. 

The  effects  of  cod-liver  oil  become  less  and  less  a  marvel  the 
more  we  know  of  physiology.  The  instinctive  desire  shown  by 
all  nations  for  an  oleaginous  diet,  and  their  association  of  sub- 
stances of  this  nature  with  proverbial  ideas  of  happiness  in  all 
ages,  show  the  value  of  a  certain  amount  of  it  to  man's  comfort. 
The  "butter  and  honey"  of  the  prophet,  used  as  a  phrase  for 


298  PULMONARY  CONSUMPTION. 

royal  food,  and  the  constant  reference  in  the  Bible  to  oil  as  a 
luxury  (though  it  could  have  been  no  rarity  in  "a  land  of  oil- 
olive") — these  are  sufficient  to  prove  its  estimation  among  the 
Hebrews.  The  Hindoo  laborer,  when  he  devours  his  gallon  of 
rice  for  a  meal,  will  spend  all  the  pice  he  can  get  on  the  clarified 
butter  of  the  country;  and  "as  good  as  ghee!"  is  his  expression 
of  unqualified  admiration.  It  was  a  mistake  in  Baron  Liebig  to 
state  that  oily  foods  are  disgustful  to  natives  of  hot  climates.  All 
races  of  men  require  them  and  seek  after  them ;  and  the  taste  of 
the  Esquimaux,  so  often  quoted,  depends  mainly  on  the  abundant 
supply  of  the  article  which  the  sea  places  at  his  disposal,  coupled 
with  a  scantiness  of  other  provisions.  Throughout  mankind  there 
is  an  instinctive  appreciation  of  the  importance  of  this  aliment, 
independent  of  accidental  difi"erences  of  nation  or  locality.  It 
seems  felt  to  be,  as  science  shows  that  it  really  is,  a  necessary 
material  for  the  renewal  of  the  tissues,  and  the  desire  for  it  be- 
comes synonymous  with  a  desire  for  augmented  life. 

An  easily  assimilated  oil  comes,  in  fact,  into  the  short  list  of 
directly  life-giving  articles  in  the  pharmacopoeia;  for  it  is  itself 
the  material  by  which  life  is  manifested.  Hence,  under  its  use, 
beneficial  influences  are  exerted  throughout  the  whole  body ;  old 
Avounds  and  sores  heal  up;  the  harsh  wrinkled  skin  regains  the 
beauty  of  youth;  debilitating  discharges  cease,  at  the  same  time 
that  the  normal  secretions  are  more  copious;  the  mucous  mem- 
branes become  clear  and  moist,  and  are  no  longer  loaded  with 
sticky  epithelium;  the  pulse,  too,  becomes  firmer  and  slower — 
that  is  to  say,  more  powerful,  for  abnormal  quickness  here  is 
always  a  proof  of  deficient  vitality.  Such  are  the  eifects,  per- 
fectly consistent  with  physiology,  of  supplying  a  sufficiency  of 
molecular  base  for  interstitial  growth. 

The  addition  of  a  small  quantity  of  alcohol  will  often  enable 
the  oil  to  be  absorbed  more  readily.  This  is  a  principle  well 
understood  by  growers  of  live  stock  for  prizes  at  agricultural 
shows,  who,  by  the  addition  of  fermenting  grains  or  spirits  to 
the  animal's  food,  often  fatten  it  more  quickly.  The  addition 
therefore  of  Avine,  whisky,  tincture  of  orange-peel,  or  of  any 
other  harmless  bitter  to  the  medicine,  is  rational,  and  may  be 


PULMONARY  CONSUMPTION.  299 

freely  conceded,  if  the  patient  finds  it  agreeable.  But  the  true 
use  of  it  as  a  remedy  or  preventive  for  tuberculosis  is  a  diiferent 
question. 

In  my  opinion  alcohol  is  not  only  useless  but  injurious  to  the 
consumptive,  excepting  for  its  beneficial  action  upon  the  mucous 
membranes.  It  arrests  and  obstructs  the  vigor  of  vital  action  ; 
by  it  growth  is  checked,  as  we  see  in  animals  artificially  kept 
small  by  dosing  with  alcohol  in  youth  without  a  sufficient  supply 
of  food,  and  in  men  who  have  early  in  life  habitually  indulged 
in  ardent  spirits.  Under  its  use  renewal  goes  on  slower,  as  we 
know  by  the  diminished  excretion  of  urea,  water,  bile,  &c.  (see 
Dr.  Booker's  "Experiments,"  and  Lecture  L.  in  this  volume), 
and  we  can  hardly  therefore  expect  it  to  be  advantageous  where 
the  continued  renewal  of  vital  powers  is  our  primary  object. 

But  you  may  fairly  ask  how  are  to  be  explained  cases  like 
the  following,  in  which  to  all  appearance  alcohol  seems  the  pre- 
servative of  life. 

J.  P.,  a  butcher,  remarkably  strong  and  stout,  was  first  at- 
tended by  me  for  delirium  tremens,  which  he  had  suffered  from 
several  times  before,  and  was  always  well  in  the  interval;  an 
attempt  to  become  a  teetotaller  was  immediately  followed  by 
galloping  consumption. 

J.  A.,  a  brewer,  came  to  me  last  year  about  indigestion  and 
pimples  (acne  rosacea)  on  his  nose  and  face;  I  urged  him  to 
give  up  brandy-drinking  before  breakfast  and  between  meals; 
and  I  find  now  a  developed  vomica  in  his  lungs,  of  which  pre- 
viously there  was  no  evidence. 

You  may  cite  instances  such  as  these,  and  attribute  the 
vomicae  to  the  omission  of  alcohol,  which  therefore  you  may 
represent  as  a  direct  preservative.  I  think  you  would  be 
wrong. 

I  confess  I  do  not  take  such  cases  as  mere  coincidences,  but 
I  explain  them  in  a  way  by  no  means  corroborative  of  the  idea 
that  spirit-drinking  keeps  off"  consumption.  I  think  that  alcohol 
acts  as  an  anaesthetic,  and  prevents  the  system  from  resenting 
the  presence  of  the  tubercles;  then,  when  it  is  left  off",  they  act 
with  doubly  deleterious  effect  on  the  body,  which  is  unprepared 


300  PULMONARY  CONSUMPTION. 

by  their  gradual  increase  to  bear  them  as  it  Avere  by  habit.  The 
quondam  tippler  is  then  in  the  same  relative  position  as  one  in 
whom  there  is  a  large  sudden  development  of  the  morbid  matter; 
for  the  existence  of  the  morbid  matter  unexpectedly  becomes 
appreciated  by  the  system,  and  its  ravages  suddenl}'  taken  notice 
of.  Thus  instead  of  really  checking  tubercular  disease,  the 
alcohol  has  acted  merely  as  a  mask,  behind  which  the  evil  has 
gone  on  unawares. 

AVhat  should  you  do  in  such  cases  as  those  above  related  ? 
Should  you  advise  a  return  to  drinking  habits?  I  think  not; 
for  though  the  symptoms  are  somewhat  lightened  thereby,  this 
is  merely  a  misty  cloud  of  anaesthesia  which  stands  between  the 
patient  and  his  pain,  and  I  doubt  if  life  is  prolonged.  More- 
over it  is  possible  to  adopt  measures  as  immediately  effectual, 
while  certainly  offering  moxe  prospective  advantages.  In  the 
last  case  which  I  quoted,  after  a  certain  struggle  with  bron- 
chitis, night-sweats,  and  emaciation,  weight  and  strength  are 
being  gained  under  cod-liver  oil  and  quinine,  although  the 
allowance  of  alcohol  is  reduced  to  that  of  a  temperate  man.* 
So  to  such  remedies  I  advise  you  to  trust  in  all  like  cases.  Here, 
as  ever,  the  appetite  must  be  your  index;  the  stomach  must  be 
the  viscus  whose  health  is  to  be  your  care. 

In  advising  foreign  travel,  again,  take  the  stomach  for  a 
guide.  At  the  dreary  time  of  the  English  year,  when  your 
patients  cannot  get  enough  light  and  exercise  to  give  them  an 
appetite,  let  them  seek  those  sunny  climes  where  the  winters 
are  the  holidays,  the  joyous  seasons  for  out-of-door  employment. 
Madeira  is  the  best.  The  next  is  that  lovely  Mediterranean 
shore  recently  annexed  to  France,  from  Cannes  to  Mentone; 
and  after  that  comes  a  long  list  of  localities  highly  praised  by 
their  inhabitants,  but  with  a  more  uncertain  climate. 

Instead  of  naming  one  place  after  another  and  thus  risking 
offence  to  a  large  number  accidentally  omitted,  I  prefer  to  give 
you  a  simple  common  sense  rule  by  which  you  may  help  your 
patients  to  make  the  best  use  of  the  winter  season. 

In  choosing  a  home  for  your  consumptive,  do  not  mind  the 

*  He  is  now  alive,  and  able  to  resume  active  business  (Sept.  18G5). 


PULMONARY  CONSUMPTION.  301 

average  height  of  the  thermometer  or  its  variations;  do  not 
trouble  yourself  about  the  mean  rainfall;  do  not  be  scientific 
at  all,  but  find  out  from  somebody's  journal  how  many  days 
were  fine  enough  to  go  out  forenoon  and  afternoon;  that  is 
the  test  you  require,  and  by  that  you  may  be  confidently 
guided. 

Do  not  suppose  all  is  done  when  you  have  chosen  a  climate. 
Your  responsibility  is  by  no  means  ended ;  you  must  be  care- 
ful in  enforcing  a  right  use  of  the  climate.  If  your  patients 
from  distaste  of  foreign  habits,  from  pining  after  home,  or  other 
causes,  take  to  moping  in-doors,  or  find  themselves  overwearied 
on  going  out,  the  sooner  they  return  to  England  the  better. 
They  are  getting  no  good,  and  they  are  running  the  risk  of 
diarrhoea,  low  spirits,  hysteria — or  still  worse,  of  failing  so  much, 
that  they  cannot  return  home,  and  must  remain  to  die,  "by 
strangers  honored,  and  by  strangers  mourned." 

But  if  they  write  you  word  that  they  are  boating,  riding, 
swimming,  sketching,  catching  lions  in  Algeria,  or  butterflies  in 
Madeira,  you  may  congratulate  yourself  on  having  added  per- 
haps months,  perhaps  years,  perhaps  luster,  to  their  lives. 

Next  to  the  stomach,  the  bowels  claim  your  main  care.  During 
this  course  of  lectures,  in  which  I  am  impressing  upon  you  the 
principles  of  restorative  medicine,  it  is  almost  needless  to  say 
that  in  pulmonary  consumption  you  are  to  shun  artificial  purga- 
tives. But  I  had  better  remind  you  of  the  importance  of  being 
on  your  guard  against  natural  diarrhoea.  Do  not  allow  it  to  go 
on  an  hour  longer  than  you  can  help.  The  best  remedies  are 
sulphate  of  copper,  hsematoxylum,  and  opium.  Chalk  mixture 
will  sometimes  act  well ;  but,  if  it  fail,  you  have  lost  valuable 
time;  so,  if  you  follow  custom  in  beginning  with  it,  do  not  be 
obstinate  in  the  continuance  of  your  remedy.  The  sulphate  of 
copper  may  be  begun  in  doses  of  one-fourth  of  a  grain,  and 
increased  up  to  two  grains,  if  required  to  be  persisted  in.  The 
haematoxylum  may  be  given  as  an  extract  in  dose  from  four  grains 
up  to  any  amount  required,  but  should  not  be  mixed  with  the 
copper,  or  you  produce  an  ink.  If  you  give  both,  let  there  be 
three  hours'  interval  between  them. 
20 


302  PULMONARY  CONSUMPTION. 

You  see  almost  daily  cases  of  consumptive  diarrhoea  checked 
sometimes  for  a  season,  sometimes  even  permanently  in  patients 
whose  disease  is  too  extensive  for  recovery.  This  is  doubtless  a 
great  point  gained,  and  some  time  added  to  life.  But  more  than 
this,  I  believe  that  the  tendency  to  deposit  tubercle  also  is  some- 
times arrested  by  arresting  the  bowel  complaint.  Just  after 
Lady-day,  1861,  Miss  Harriet  B.,  aged  thirty,  whose  "father  and 
mother  had  both  died  of  decline,"  was  placed  under  ray  care  by 
Dr.  Buckell,  of  Chichester.  She  had  evidence  of  a  small  focus 
of  tubercle  in  the  apex  of  the  left  lung,  producing  pain,  dullness, 
and  crepitation  (from  the  partial  condensation  of  the  lung  round 
it),  but  no  marked  pulmonary  ailment.  I  thought  that  the  quan- 
tity of  tubercle  was  slowly  increasing  from  week  to  week.  What 
she  complained  of,  however,  was  emaciation  and  diarrhoea,  accom- 
panied by  the  passage  of  pus,  and  sometimes  streaks  of  blood  in 
the  mucous  faeces.  She  was  soon  relieved  of  this  by  appropriate 
remedies;  and  with  a  store  of  hrematoxylum  and  copper  was  able 
to  ffo  on  a  long  summer  visit  to  some  friends.  I  heard  of  her  as 
going  on  well,  and  did  not  expect  to  see  her  again,  or  to  make 
her  case  available  for  science.  But  as  she  returned  through 
London  in  September,  proclaiming  herself  quite  well  and  stout, 
I  had  an  opportunity  of  examining  her  chest  again  ;  and  much 
to  my  delight  was  it  that  I  did  so.  Greatly  to  my  surprise,  I 
could  detect  no  disease  at  all  in  the  lung ;  so  that,  instead  of 
increasing,  as  I  had  feared,  the  pulmonary  tubercle  had  become 
dormant,  solely  by  the  cure  of  the  bowel  complaint.  Not  all 
cases  do  as  well  as  this,  but  still  what  has  once  befallen  may 
befall  again,  and  it  is  the  surest  road  to  success  to  hope  and  try 
for  it. 


{Clmical,  St.  Marys,  June  7,  1862.) 

In  some  cases  of  consumption  there  is  a  considerable  amount 
of  cachexia,  the  gums  become  spongy,  or  whitlows  form  on  the 
fingers,  or  there  are  various  kinds  of  skin  diseases.  This  hap- 
pens usually  in  consequence  of  low  living,  damp,  and  depression 
of  mind. 


PULMONARY  CONSUMPTION.  303 

There  is  now  in  Victoria  ward  a  girl  of  sixteen,  who  was  trans- 
ferred from  a  surgical  ward.  She  was  at  first  in  a  deplorable 
condition;  she  had  been  admitted  for  impetigo,*  with  which  her 
cheeks  and  nose  were  covered,  while  the  pads  of  her  finger-tips 
and  nails  were  sore  and  purulent  from  the  same  eruption.  Yet  the 
impetigo  did  not  account  for  colliquative  night-sweats,  extreme 
emaciation,  and  weakness  so  great  that  she  could  not  raise  her- 
self in  bed  :  these  symptoms  were  explained  by  dullness  at  the 
apices  of  the  lungs  and  localized  rales,  indicative  of  tubercular 
condensation.  Some  thought  there  was  a  vomica  at  one  apex, 
on  account  of  the  cracked-pot  sound  on  percussion,  but  it  was 
a  doubtful  point — the  cracked-pot  sound  is  a  very  fallacious  sign. 
She  did  not  behave  as  if  there  was  a  vomica,  for  she  has  been 
gaining  strength  and  flesh  daily  up  to  this  time.  My  reason  for 
recalling  this  case  to  you  is  to  notice  that,  in  spite  of  tonics  and 
high  feeding,  before  she  came  under  my  care  she  had  been 
getting  weaker  and  weaker.  The  only  change  I  made  was  to 
give  with  her  tonic  mixture  half  a  drachm  of  chlorate  of  potash 
daily  in  some  cod-liver  oil — I  confess  with  but  little  hope  that 
she  should  revive.  I  was  never  so  struck  before  by  the  directly 
vitalizing  force  of  this  salt  upon  connective  tissue.  In  a  fortnight 
her  "flesh  came  again  like  unto  the  flesh  of  a  little  child,"  as 
the  Hebrew  historian  beautifully  expresses  it;  the  clear  doll-like 
complexion  of  face  and  the  pink  babyish  finger-tips  are  very 
pretty.  And  I  have  no  doubt  that  a  like  quickening  has  gone 
on  in  the  skins  of  the  inside — the  mucous  membranes — so  much 
strength  and  appetite  has  she  gained. 

This  case  shows  you  when  to  give  chlorate  of  potash  in  con- 
sumption with  hope  of  profit.  And  I  am  glad  you  have  the 
opportunity  of  seeing  this,  because  a  short  time  ago  chlorate  of 
potash  blazed  forth  as  a  cure  for  phthisis  in  general ;  and  if  you 
have  tried  and  found  it  wanting  in  some  ordinary  instance,  you 

*  Impetigoz=.^'- ?i  superficial  formation,  consisting  mainly  of  jo^m  from  the  de- 
nuded connective  tissue  of  the  corium,  without  external  exciting  causes." 

Eczeviazzz'-'-  the  same  of  serum." 

I  do  not  propose  these  as  dogmatical  definitions,  for  dermatologists  are  a  difiB- 
cult  race  to  please,  but  simply  to  explain  what  I  myself  mean  by  the  words. 


304  PULMOXARY  CONSUMPTIOX. 

might  be  tempted  to  treat  with  undeserved  contempt  a  medicine 
of  really  great  service  in  proper  cases. 


[Clinical,  St.  Mary»,  February  6,  1864.) 

On  my  last  admission  day,  January  29,  there  were  received 
under  my  care  two  very  distressing  cases  of  consumption.  Both 
were  in  the  extremest  state  of  emaciation  and  exhaustion  from 
suppurating  vomicae  in  the  lungs,  and  so  far  presented  a  spect:icle 
which  is  sadly  familiar  to  the  medical  man.  In  addition,  the 
woman  was  purple  in  the  lips  and  face  from  intercurrent  pneu- 
monia, the  man  was  in  a  cold  sweat,  and  had  diarrhoea.  But  the 
symptom  exhibited  by  both  in  common,  which  leads  me  to 
mention  the  cases  to-day,  is  one  not  quite  so  usual  as  these,  yet 
sufficiently  usual  to  make  it  of  practical  importance.  I  allude  to 
delirium.  The  man  got  temporarily  somewhat  better  of  it  after 
a  few  days'  residence  in  the  hospital,  so  that  his  mind  wandered 
only  at  night,  but  the  woman  has  been  disturbing  the  ward  with 
her  continuous  ravintrs,  has  been  verv  violent,  exerting  her  small 
remains  of  strength  to  throw  the  beef-tea  at  the  nurse.  She 
uses  such  abominable  language  that  it  has  become  necessary  to 
place  her  in  a  room  by  herself. 

Delirium  at  the  latter  end  of  exhaustive  diseases  is  a  sign  of 
the  participation  of  the  nervous  tissue  in  the  destruction  which 
is  going  on  among  all  the  tissues  of  the  body.  It  answers  to  the 
convulsions  and  obtuseness  of  sense,  which  M.  Chossat  observed 
in  animals  starved  to  death.*  The  nervous  system  being  the 
ultimum  moriens  of  the  body,  suffers  last,  but  does  suffer  in  the 
end. 

This  delirium  is  commonly  accompanied  by  deafness,  and  is  so 
accompanied  in  the  two  cases  before  us.  I  cannot  say  I  have 
been  able  to  trace  a  corresponding  deficiency  in  the  organs  of 
sight,  but  certainly  the  taste  and  general  sensation  are  deficient. 
The  pain  in  the  chest  and  suffocation,  which  the  poor  woman  com- 
plained of  on  admission,  are  denied  now  that  the  raving  is  worse, 
and  she  does  not  appear  to  know  food  from  medicine. 

*  See  before,  pages  30 — 40  of  ibis  volume. 


PULMONARY  CONSUMPTIOX.  305 

The  immediate  cause,  to  which  I  have  most  usually  seen  occa- 
sion to  attribute  it,  has  been  unwonted  and  excessive  bodily  exer- 
tion, at  a  time  when  extreme  rest  constitutes  the  only  possible 
means  of  economizing  the  vital  power.  I  have  no  doubt  but 
what  it  was  the  being  brought  out  of  their  beds  to  the  hospital 
which  made  these  patients  so  much  worse  directly  on  their  arri- 
val, and  which  threatens  to  shorten  their  lives. 

In  those  who  die  no  morbid  change  in  the  nerve  substance  is 
visible  after  death,  though  the  symptoms  during  life  generally 
cause  it  to  be  carefully  looked  for.  This  fact  is  familiar  enough 
to  those  who  have  the  inestimable  pathological  privileges  of  n 
public  institution  ;  but  I  think  it  is  often  unknown  to  others;  and, 
consequently,  the  natural  connection  in  their  minds  between  the 
increase  of  symptoms  and  the  spread  of  tubercle  in  consumptive 
cases  is  apt  to  lead  to  their  assigning  the  delirium  we  are  con- 
sidering to  a  development  of  tubercle  in  the  brain.  Two  months 
ago  an  old  gentleman  in  the  last  stage  of  senile  phthisis  was 
brought  up  from  the  country  by  his  family,  contrary  to  the  excel- 
lent advice  of  their  own  medical  man,  to  obtain  "  a  London 
opinion."  I  believe  they  had  already  taken  him  to  one  physician 
previously,  when  he  arrived  excited  in  mind  and  worn  out  in 
body,  in  my  study.  I  felt  much  relieved  when  a  glass  of  Madeira 
enabled  him  to  be  got  back  to  the  carriage,  for  I  should  not  have 
been  much  surprised  at  his  dying  in  my  house  ;  and  you  may 
easily  imagine  that  I  rebuked  the  folly  of  his  friends  in  strong 
language.  However,  he  did  get  home.  But  very  soon  he 
became  delirious  and  raving,  as  I  learned  by  letter ;  and  I  found 
that  this  delirium  was  attributed  by  those  who  attended  him  in 
the  country  to  tuberculosis  of  the  brain.  The  idea  is  a  natural 
one,  but  it  might  have  injured  the  patient  had  it  influenced  the 
treatment.  His  death  in  delirium  was  indubitably  due  to  the 
almost  superstitious  folly  of  his  friends  in  bringing  him  up  to 
London. 

As  to  treatment,  opium,  wine,  and  continuous  nutriment  seem 
indicated,  and  to  be  of  some  use;  but  such  cases  of  extreme  dis- 
ease are  not  usefully  illustrative  of  medical  regimen.  The  man 
has  been  better  since  he  began  cod-liver  oil  and  quinine,  and 


306  PULMONARY  CONSUMPTION. 

perhaps  the  nourisliing  thus  the  nervous  tissue,  if  the  food  can 
be  assimihited,  is  the  best  application  of  restorative  principles. 


{CKnical,  St.  Marys,  May  10,  1862.) 
******** 

I  am  induced  to  add  a  few  words  about  so-called  specifics  for 
consumption.  Some  years  age,  Dr.  John  Hastings  proclaimed 
"naphtha"  as  an  unerring  cure.  Some  people  tried  it,  and 
soon  learnt  that  it  was  applicable  at  all  only  in  cases  where 
alcohol  was  beneficial,  and  even  to  such  patients  they  found 
that  the  purer  and  wholesomer  forms  of  spirit  in  daily  use  were 
both  more  useful  and  more  acceptable.  All  the  advantages  of 
the  remedy  had  been  in  the  hands  of  the  public  in  a  pleasanter 
form  centuries  ago.  Determined  at  last  to  try  a  virgin  sub- 
stance— 

— "integros  accedere  fontes 
Atque  baurire" — 

the  same  gentleman  has  recently  discovered  that  serpents'  dung 
now  succeeds  to  the  throne  where  once  naphtha  reigned.  Our 
rude  forefathers  in  art  administered  many  curious  things;  the 
ashes  of  toads,  the  urine  of  boars,  live  spiders,  human  liver, 
human  ordure,  the  skull  of  a  murdered  man,  the  blood  of  the 
patient's  father,  and  other  gatherings  from  witches'  caldrons, 
are  in  their  lengthy  pharmacopoeias,  and  are  many  of  them 
stored  in  that  interesting  collection  of  ancient  articles  of  materia 
medica  at  the  College  of  Physicians.  Their  intention  was  to 
drive  out  the  devil  by  digusting  him.  But  I  do  not  think  that 
they  ever  hit  upon  the  bright  thought  of  using  the  very  dung  of 
the  accursed  type  of  evil,  that  as  he  indignantly  "goes  out,"  he 
may  say, 

"  That  eagle's  fate  and  mine  are  one, 
Who  in  the  shaft  that  made  him  die 
Beheld  a  feather  of  his  own 

Wherewith  he  wont  to  soar  so  high." 

I  really  believe  this  expansion  of  the  idea  to  be  quite  original. 
Good  coprologists  tell  us  that  the  excreta  of  snakes,  foeces 


PULMONARY  CONSUMPTION.  307 

and  urine  in  one,  consist  mainly  of  lithate  of  ammonia — an  un- 
attractive substance,  which  persons  familiar  with  physiology 
believe  to  be  harmless,  and  valuable  only  as  manure.  I  rested 
content  with  that  belief  till  I  heard  Dr.  Hastings,  when  arraigned 
before  a  public  court  of  justice  for  the  avaricious  raalpraxis  of 
knowingly  giving  inert  remedies,  depose  positively  on  oath  that 
he  held  what  he  administered  to  be  a  powerful  physiological 
agent.  His  powerful  physiological  agent  was  made  by  dissolv- 
ing {i.e.  destroying)  sixteen  grains  of  boa  constrictor's  ejecta  in 
a  gallon  of  water  by  the  addition  of  bromine,  of  which  the  dose 
is  half  an  ounce.  Such  a  solemn  affirmation  was  not  to  be  lightly, 
treated,  and  after  that  I  did  not  feel  justified  in  asserting  dung 
to  bo  a  useless  drug  till  I  had  tried  it.  I  procured  forthvfith 
a  sample  from  the  secretary  of  the  Zoological  Society,  and  caused 
to  be  made  a  quantity  of  the  so-called  "solution"  under  the 
name  of  "mistura  pythonis,"  and  you  have  seen  me  order  it 
pretty  often  since  in  cases  where,  no  physic  being  required  for 
a  time,  I  felt  myself  justified  in  so  doing.  But  instead  of  half 
an  ounce,  which  was  said  by  the  witness  to  be  so  active,  I  have 
given  two  ounces  three  times  a  day.  You  have  seen  that  its 
efi'ects  are  exactly  the  same  as  those  of  so  much  ditch  water. 

Such  is  the  fate  of  specifics  for  phthisis — ex  uno  disce  omnes — 
and  lucky  is  the  public  if  all  specifics  are  as  innocent  as  snakes' 
dung. 

But  do  not  let  us  part  without  a  moral,  or  be  satisfied  with 
merely  laughing  at  a  delusion,  liemember,  you  are  acting  no 
better  than  the  vaunters  of  vain  specifics  when  you  vaguely  pre- 
scribe one  thing  or  another,  even  of  known  and  acknowledged 
power,  because  you  have  heard  of  its  being  "good  for  consump- 
tion." The  time  which  is  lost  in  trying  this  and  trying  that 
remedy  is  lost  for  ever.  You  have  no  warrant  for  supposing 
that  there  can  be  any  specific  for  that  complex  morbid  state 
which  causes  phthisis;  you  have  no  warrant  for  substituting  a 
vague  search  after  such  specifics  for  rational  treatment;  nor  can 
you  justify  yourself  for  standing  in  the  way  of  the  patient  get- 
ting his  chance  of  a  renewal  of  his  waning  life  by  the  unsparing 
use  of  restorative  agents. 


308  PULMONARY  CONSUMPTION. 

The  proper  persons  upon  whom  to  try  the  effects  of  new  reme- 
dies in  the  first  instance  are  not  the  sick,  but  the  healthy  or 
nearly  healthy.  If  no  obvious  results  follow  the  use  of  full 
doses  by  yourself  or  another  free  from  present  illness,  you  may 
be  pretty  certain  the  same  will  be  the  case  with  your  patients. 
There  are  always  to  be  found  in  hospitals  specimens  of  malin- 
gerers and  "old  soldiers,"  and  convalescents,  upon  whom  it  is 
quite  safe  to  try  these  experiments  under  proper  supervision, 
so  as  to  satisfy  any  doubts  you  may  have.  Or  if  you  have  no 
doubts  to  begin  with,  you  will  thus  gain  a  right  to  make  the 
shortest  and  most  telling  answer  to  inquiries  of  "How  does  such 
and  such  a  cure  succeed?"     "I've  tried  it  and  it  is  useless." 

You  should  make  it  a  rule  absolute,  that  objective  phenomena 
rather  than  subjective  are  to  be  taken  as  tests,  and  that  all 
things  are  to  be  "delivered  in  number  and  weight,"  according 
to  the  sage  advice  of  the  Son  of  Sirach.  For  instance,  if  you 
were  examining  the  action  of  quinine,  the  changes  of  tempera- 
ture must  be  estimated  by  the  thermometer,  the  changes  of  urine 
in  the  laboratory,  the  action  on  the  skin  from  the  amount  of 
perspiration.  And  you  must  not  waste  time  by  performing  ex- 
periments which  do  not  admit  of  objective  proof. 


LECTURE    XXIV. 

THORACIC    ANEURISM. 

First  case — Aneurism,  probably  of  the  arteria  innominata — 
Reasons  for  that  diagnosis — Aortic  valvular  murmur  ac- 
counted for — Probable  abnormal  position  of  artery — Prognosis 
unfavorable — Second  ease — Aneurism  of  aorta  and  its  treat- 
ment— Bloodletting  and  low  diet — Pathology  of  aneurism — 
Object  of  treatment — Favorable  prognosis — Two  cases  of  favor- 
able result  of  treatment — Fatal  case  of  aortic  aneurism — 
Rupture  of  sac  into  the  pleura  in  a  healthy  working  man — ' 
Length  of  time  a  patient  may  live  with  a  ruptured  aorta  an 
encouragement  to  treatment — Case  of  aneurism  compressing 
the  trachea,  producing  congestion  of  the  lungs,  and  so  fatal — 
Actions  of  bleeding,  leeching,  and  digitalis — Action  of  digitalis 
on  other  involuntary  fibers,  as  on  the  uterus  in  menorrhagia, 
and  on  the  bladder  in  incontinence  of  urine. 

[Clinical,  St.  Mary's,  January  5,  1861.) 

I  TAKE  the  opportunity  of  having  two  patients  in  the  wards 
afflicted  with  aneurism  of  that -sort  which  alone  comes  under  a 
physician's  care,  viz.,  thoracic  aneurism,  to  call  your  attention 
to  the  medical  aspects  of  the  lesion. 

The  board  admitted,  yesterday,  into  Victoria  ward  a  young 
woman  of  twenty-two,  who  has  been  a  patient  of  mine  in  the 
Lock  Hospital.  She  has  had  syphilis  on  and  oflF  ever  since  the 
age  of  fourteen;  and  though  the  eruptions  and  sores  are  now 
healed,  her  health  is  much  broken,  and  she  is  stunted  and 
weakly.  She  applies  at  St.  Mary's  not  for  her  old  complaint, 
but  on  account  of  palpitations,  and  pain  across  the  front  of  the 
chest,  which  she  states  that  she  has  felt  for  three  years,  but 


310  THORACIC  ANEURISM. 

which  lately  had  got  much  worse.  She  also  frequently  suflfers 
from  giddiness  and  fainting;  and  last  Sunday  was  carried  out 
of  chapel  in  a  dead  swoon.  A  message  has  just  come  to  say 
that  on  account  of  one  of  these  attacks  she  is  unable  to  come 
down  to  the  theater,  as  I  bade  her. 

She  often  has  a  difficulty  in  swallowing  food,  especially  solid 
food. 

She  states  that  she  has  very  partial  use  of  the  left  arm ;  and, 
on  examination,  it  is  smaller  in  girth  to  a  marked  degree,  and 
the  muscles  are  flabbier  than  on  the  right  side.  No  pulse  can 
be  felt  at  the  left  wrist,  nor  at  the  bend  of  the  elbow,  nor  on  the 
inner  side  of  the  biceps.  The  axillary  artery  can  be  felt  beating 
very  feebly  above  the  collar-bone. 

In  a  marked  contrast  to  this  stands  the  right  side.  The  pulse 
at  the  wrist  is  natural,  and  above  the  collar-bone  may  be  per- 
ceived a  strong  pulsation,  and  at  the  origin  of  and  for  an  inch 
or  more  along  the  carotid  artery  a  very  distinct  thrill.  In  the 
hollow  above  the  sternum  the  same  pulsation  is  even  stronger, 
and  throws  forward  the  trachea,  when  you  press  upon  it  with 
your  finger. 

With  a  stethoscope  a  purring  whiz  is  heard  in  the  same  situ- 
ation as  the  pulsation  is  felt.  A  murmur  is  heard  also  at  the 
upper  part  of  the  sternum,  and  is  particularly  loud  on  the 
level  of  the  fourth  costal  cartilage,  where  it  sometimes  has  a 
musical  tone.  There  is  no  dullness  on  percussion  beneath  the 
clavicle. 

My  diagnosis  of  this  case  is,  that  she  has  an  aneurism  of  the 
ascending  aorta  at  the  part  where  the  innominata  is  given  off, 
and  that  this  lesion  involves  the  innominata  and  the  origin  of 
the  carotid  artery.  I  do  not  think  it  an  enlargement  of  the  in- 
nominata alone,  because  of  its  being  situated  so  much  at  the  back 
of  the  trachea  as  to  throw  the  tube  forward  by  its  pulsations  and 
also  to  press  upon  the  oesophagus,  and  interfere  with  deglutition. 
Besides,  in  the  only  case  I  have  seen  during  life  of  pure  aneurism 
of  the  innominata,  proved  to  be  so  after  death,  the  tumor  was 
smaller  and  rounder,  and  pointed  more  distinctly  in  the  supra- 
clavicular hollow. 


THORACIC  ANEURISM.  311 

You  have  here  nearly  all  the  signs  of  aneurism  of  the  aorta 
— (1)  pulsation ;  (2)  whiz  ;  (3)  impaired  deglutition  ;  and  (4)  im- 
peded circulation. 

But  you  may  say  there  is  the  same  whiz  at  the  aortic  valves. 
What  is  the  cause  of  that  ?  It  is  not,  I  think,  produced  directly 
by  aortic  aneurism,  but  it  is  produced  by  the  same  original 
cause.  Aneurism  forms  because  there  is  a  friability  or  loss  of 
elasticity  in  the  coats  of  the  vessel,  due  generally  to  a  deposit 
of  white  opaque  matter  and  to  a  partial  degeneration  of  them. 
"What  is  more  likely  than  the  existence  of  the  same  disease  in  the 
aortic  valves  ? 

Now  I  come  to  the  puzzling  part  of  the  case.  You  will  ob- 
serve that  the  right  axillary  artery  is  quite  free  ;  there  is  quite 
an  open  passage  through  it  to  supply  the  radial  at  the  right 
wrist.  Yet  it  is  in  this  supraclavicular  space  that  we  have  the 
pulsation  and  whiz  ;  whereas  the  left  axillary,  though  it  has  nor- 
mally nothing  to  do  with  the  innominata,  is  not  supplied  with 
blood,  and  the  left  arm  is  atrophied. 

I  can  account  for  this  in  one  way,  which  I  might  as  well  de- 
tail, though  it  is  more  a  matter  of  curiosity  than  of  business.  (I 
do  not  bind  you  to  accept  the  interpretation ;  and  if  any  of  you 
fresh  from  the  anatomy  school  can  suggest  a  better,  I  shall 
receive  it  with  pleasure.)  In  many  beasts,  in  the  ruminants  and 
solidungula,  and  in  some  pachydermata — as  for  instance,  the 
hog — the  aorta  divides  into  two  branches,  the  ascending  giving 
off  the  two  subclavians  and  the  two  carotids,  while  the  other 
turns  backward  and  becomes  the  descending  aorta.  On  this  has 
been  founded,  by  the  earlier  anatomists,  the  popular  division 
of  the  aorta  into  "ascending"  and  "descending,"  a  division  un- 
intelligible in  the  human  species,  but  exceedingly  applicable  to 
the  domestic  animals  whence  the  ancient  men  of  science  learnt 
their  anatomy.  It  is  by  no  means  impossible  that  the  patient 
before  us  may  have  a  malformation,  which  is  an  approach  to 
this  lower  condition  of  animal  life — a  malformation,  of  which 
specimens  may  be  seen  in  many  museums :  namely,  where  the 
left  subclavian,  as  well  as  the  right,  is  given  off  by  the  innomi- 
nata, and  has  to  cross  over  the  arch  of  the  aorta  to  get  to  its 


312  THORACIC  ANEURISM. 

work  ;  and  in  this  crossing  it  would  be  interfered  with  by  the 
tumor  of  the  top  of  the  arch.  I  cannot  otherwise  unravel  the 
enigma,  as  the  tumor  is  not  large  enough  to  obstruct  a  normal 
left  subclavian.  As  an  argument  in  support  of  the  explanation, 
I  may  mention  that  the  patient  has  a  congenital  deficiency  of 
the  reproductive  organs,  curious  in  a  social  point  of  view  to  find 
in  a  person  of  her  degrading  habits,  for  she  is  a  common  prosti- 
tute. She  has  no  uterus,  the  vagina  ending  in  a  short  cul-de- 
sac.  A  malformation  in  one  part  is  a  probable  argument  for  it 
in  another. 

This  aneurism  presents  several  points  which  lead  me  to  pro- 
nounce an  unfavorable  prognosis.  First.  It  is  in  the  ascending 
part  of  the  aorta.  Now,  you  will  find  that  almost  all  aneurisms 
of  the  ascending  aorta  are  rather  dilatations  than  aneurismal 
sacs.  They  have  no  sharp  edge  opening  out  suddenly  into  a  dis- 
tinct bag.  And  these  dilatations  are  more  difficult  of  cure  than 
the  sharp-edged  sacs,  because  there  is  a.  clear  stream  through, 
and  no  back  current,  so  that  you  cannot  get  clots  to  form  in 
them.  Secondly.  The  absence  of  clots  is  confirmed  by  the 
strength  of  the  thrill.  Thirdly.  The  supply  of  blood  to  the  brain 
is  seriously  diminished,  as  is  shown  by  her  fainting  fits.  Fourthly. 
The  impeded  deglutition  and  the  suspected  malformation  are  dis- 
couraging. Fifthly.  She  is  a  poor  anaemic  woman,  reduced  by 
poverty,  syphilis  and  mercury  to  a  very  low  state,  and  she  will 
not  bear  lowering  treatment,  I  am  sure.  Sixthly.  She  is  said  to 
have,  like  most  of  her  unhappy  class,  a  violent  temper  ;  so  it  will 
be  difficult  to  detain  her  in  the  hospital,  or  to  keep  her  circula- 
tion quiet  while  there.*  It  is  doubtful  how  far  we  shall  be  able 
to  apply  the  treatment  suitable  for  the  disease,  and  how  far  it 
will  prosper,  if  applied.  What  that  treatment  is,  I  shall  best 
tell  you  after  the  next  case. 

Henry  E.,  a  negro,  aged  twenty-one,  came  under  my  care 
two  months  ago — viz.,  on  November  9.  Though  now  a  com- 
mercial traveler,  during  the  Crimean  war  he  was  a  sailor  in  a 
transport,  and  during  that  time  he  got  a  severe  blow  on  the 

*  Very  soon  afterwards  it  was  necessary  to  tura  her  out  of  the  hospital  for 
gross  misconduct,  and  I  have  not  been  able  to  find  what  became  of  her. 


THORACIC  ANEURISM.  313 

back  of  the  neck  from  a  "derrick."  He  says  he  never  had 
cough  or  shortness  of  breath,  and  was  always  "  strong  in  the 
chest,"  till  he  began  to  feel  a  pain  there  in  August  last,  especially 
between  the  left  nipple  and  the  collar-bone.  This  pain  increased 
gradually,  though  intermittingly,  through  the  autumn.  Three 
days  before  we  saw  him,  while  he  was  at  his  tea  in  Windsor,  it 
suddenly  increased  very  much,  and  he  says  he  felt  "  as  if  some- 
thing was  going  up  and  down  from  his  heart  to  his  arm."  He 
fell  down,  was  struck  dumb,  and  found  that  he  had  lost  the  use 
of  the  left  arm.  On  his  admission,  it  was  found  that  the  pulse 
in  that  wrist  was  much  weaker  than  in  the  right,  and  tliere  was 
loss  of  power,  though  not  absolute  paralysis,  throughout  the 
limb.  The  throat  was  externally  swelled  on  the  left  side,  and 
the  carotid  could  scarcely  be  felt.  There  was  considerable  swel- 
ling of  the  whole  mammary  and  infraclavicular  regions,  in  which 
latter  also  there  could  be  distinctly  made  out  comparative  dull- 
ness on  percussion.  This  dullness  was  more  distinct  on  the 
third  rib  than  immediately  beneath  the  collar-bone.  On  ap- 
plying the  stethoscope  to  the  third  rib,  a  distant  whizzing  mur- 
mur could  be  heard,  which  increased  in  intensity  in  nearing  the 
shoulder,  and  was  less  loud  towards  the  sternum.  There  was 
no  pulsating  tumor,  and  the  lung-sounds  were  natural,  except 
perhaps  rather  more  bronchial  on  the  left  side  than  on  the  right. 
There  was  a  breathing  pulsation  in  the  left  jugular  vein. 

The  signs  of  aneurism  were  not  so  distinct  as  in  the  last  case, 
because  it  did  not  come  so  near  the  surface.  1  am  inclined  to 
think  it  is  towards  the  back  of  the  descending  part  of  the  arch  ; 
but  wherever  its  exact  locality  may  be,  it  evidently  interfered 
with  both  arteries,  veins,  and  nerves,  which  supply  the  arm,  in- 
tercepting the  pulse-wave  and  the  nervous  current,  and  causing 
anasarcous  tumefaction  from  its  obstruction  to  the  return  of  blood 
by  the  veins. 

Local  treatment  was  desirable,  and  leeches  were  applied  seve- 
ral times  beneath  the  clavicle.  He  would  have  been  bled  also; 
but  five  days  after  admission  he  fortunately  caught  scarlet  fever 
from  a  neighboring  patient,  and  it  struck  me  that  this  might 
prove  a  substitute  for  venesection  ;  for  it  gave  us  a  plea  for  keep- 


314  THORACIC  ANEURISM. 

ing  him  a  close  prisoner  in  bed,  and  putting  him  on  very  low  diet. 
This  plan  was  the  easier  carried  out  from  his  being,  like  most 
civilized  Africans,  of  a  mild  tractable  disposition,  and  it  has  been 
pursued  steadily  up  to  the  present  time.  On  December  1,  it  is 
noted  by  the  clinical  clerk  that  he  had  recovered  power  over  the 
arm,  and  that  the  pulses  appeared  nearly  equal.  He  has  con- 
tinued the  complete  rest,  and  has  taken  prussic  acid  and  digitalis. 
There  is  now  no  difference  to  be  detected  between  the  radials, 
and  he  has  regained  complete  use  of  the  arm  ;  he  describes  him- 
self as  quite  well  enough  to  be  an  out-patient,  and  finds  a  band- 
age which  he  wears  across  the  chest  sufficient  to  relieve  the 
occasional  pains.  There  is  a  murmur  still  in  the  infraclavicular 
region ;  but  all  impediment  to  circulation  occasioned  by  the 
aneurism  has  ceased. 

The  treatment  which  has  been  adopted  here  is  an  exemplifi- 
cation of  the  principles  which  I  have  taught  in  the  systematic 
lectures  on  the  principles  of  medicine,  and  I  must  refer  you  to 
those  lectures  for  an  historical  account  of  the  adoption  of  this 
practice  in  the  seventeenth  century  by  Valsalva.  It  is  a  strict 
following  up  of  that  which  nature  adopts  in  all  aneurisms  that 
heal  spontaneously.  In  them  you  find  a  fibrinous  clot  formed, 
and  the  sac  shrunken  up  from  lack  of  stream  passing  through 
it.  Here  we  have  tried  to  make  the  blood  likewise  form  fibrin- 
ous clots,  by  bringing  it  into  that  fibrinous  state  which  loss  of 
blood,  angemia,  and  low  diet  induce ;  and  we  have  tried  to  keep 
the  blood-stream  as  calm  as  possible  by  rest  in  the  horizontal 
posture. 

The  pathology  of  aneurism  shows  it  to  us  as  a  local  deficiency 
of  life  in  a  hollow  organ,  a  deficiency  of  vital  elasticity,  which 
has  let  this  hollow  organ  yield  to  the  continuous  pressure  of  the 
blood-stream.  Doubtless  if  we  could  at  first  have  renewed  this 
vital  elasticity,  such  would  have  been  the  legitimate  aim  of 
treatment,  and  such  would  be  the  course  pursued  by  a  rational 
physician.  But  here  the  mischief  is  already  done,  the  vessel  has 
dilated  into  an  uncontractile  sac  and  is  beyond  the  reach  of  any 
of  the  poAvers  of  life.  The  object  now  must  be  to  restore  as 
much  as  possible  the  original  area  of  the  vessel,  and  to  reinforce 


THORACIC  ANEURISM.  315 

the  weakened  walls  bj  an  artificial  clot ;  so  that  though  we 
cannot  have  a  complete  artery,  we  may  have  as  good  a  substi- 
tute for  it  as  circumstances  will  allow. 

There  was  much  in  favor  of  this  patient  from  the  outset :  the 
aneurism  was  in  the  descending  aorta  ;  there  was  no  thrill ;  his 
general  health  was  good ;  and  he  is  an  obedient  quiet  creature, 
very  different  from  the  ill-conditioned  little  woman  last  dis- 
cussed. At  all  events  he  has  done  very  well ;  and  I  should 
urge  upon  you  to  make  the  carrying  out  of  this  principle  of 
treatment  the  goal  of  your  wishes  in  thoracic  aneurism.  You 
will  find  patients  very  often  rebel ;  but  do  your  best,  and  if  you 
attain  not  success,  you  will  at  any  rate  deserve  it. 

I  like  in  general  to  bleed  the  patients  ajQfected  with  aneurisms 
from  time  to  time,  and  should  have  employed  that  mode  of 
treatment  if  this  man  had  not  had  the  scarlet  fever.  A  former 
patient  of  Dr.  Sibson's,  now  an  out-patient,  testifies  from  his 
own  observation  to  the  superiority  of  venesection  over  leeches 
in  its  calmative  influence  over  an  aoritic  aneurism  which  he  has 
long  had,  and  on  which  he  is  very  observant  to  the  effect  of 
remedies.  But  I  have  heard  an  opposite  opinion  given  by 
patients. 

I  said  you  will  deserve  success,  and  sometimes  you  will  get  it. 
I  kept  a  stone-mason  in  this  hospital  under  the  bleeding  and 
starving  treatment  for  five  weeks.  He  had  como  in  with  a  pul- 
sating tumor  and  aneurismal  whiz  under  the  left  scapula,  with 
severe  pain  in  the  floating  ribs,  which  some  thought  were  being 
absorbed.  At  the  end  of  the  five  weeks  he  rebelled,  and  our 
relation  as  physician  and  patient  was  at  an  end;  but  the  pulsa- 
tion had  disappeared,  and  the  whiz  was  scarcely  to  be  heard ; 
and  I  had  reason,  therefore,  to  think  the  aneurism  in  a  fair  way 
to  be  cured. 

Even  in  cases  where  the  treatment  cannot  be  carried  out  a 
Voutrance,  good  may  be  done  by  an  approach  to  it.  In  1851,  a 
lady  was  sent  to  me  by  a  surgeon  in  the  country,  to  consult  me 
about  increasing  corpulence  and  dyspnoea.  In  investigating  the 
cause  of  dyspnoea,  I  found  a  pulsation  and  an  obscure  whiz 
under  the  left  clavicle,  accompanied  by  deficiency  of  pulse  in 


316  THORACIC  ANEURISM. 

the  left  wrist.  I  was  satisfied  that  there  was  aneurism  either  of 
the  subclavian  or  of  the  aorta  at  the  origin  of  that  branch. 
But  bleeding  was  undesirable,  because  she  was  so  fat.  I  have 
often  told  you  how  badlj  obese  people  bear  bleeding.  Moreover 
she  was  sixty  years  of  age.  But,  as  she  was  a  sensible  woman, 
I  managed  to  gain  her  confidence,  and  starved  her  for  several 
weeks,  giving  her  at  the  same  time  drachm  doses  of  liquor 
potassse  three  times  a  day.  The  effect  was  a  reduction  of  her 
corpulence,  a  diminution  of  the  pulsation  in  the  tumor,  and 
greater  freedom  of  breathing.  I  did  not  see  her  from  1851  till 
1856,  when,  being  in  London,  she  called  to  show  herself,  saying 
how  well  she  was.  The  pulse  in  the  radial  artery  had  not  re- 
turned; but  there  was  no  beating  in  the  tumor,  and  only  a  sort 
of  roughness  in  the  sound  of  the  artery.  She  felt  confident  her- 
self of  the  good  effect  of  the  starving  treatment. 

I  have  taken  the  opportunity  of  your  having  two  patients 
together  under  your  eye  to  bring  the  subject  of  aneurism  before 
you,  because  of  late  the  objections  urged  against  venesection  in 
excess  and  in  improper  cases  have  produced  a  fashion  of  decry- 
ing its  use  altogether,  and  especially  in  thoracic  aneurism. 
Bleeding  and  starving,  it  is  urged,  induce  debility  and  aneemia ; 
that  is  to  say,  in  physiological  language,  they  lower  the  force 
of  the  heart,  and  they  cause  a  comparative  excess  of  fibrine 
over  blood-disks  in  the  blood.  These  are  both  steps  towards 
the  mode  adopted  in  nature  to  effect  a  cure  of  aneurism,  and 
perhaps  of  some  other  diseases  also.  So,  that,  I  contend,  not 
merely  is  it  the  best  mode,  but  the  only  honest  mode,  of  treat- 
ing aneurism  of  the  trunk-vessels  ;  because  it  is  the  only  one  we 
at  present  know  consonant  to  reason  and  experience. 


{Clinical,  St.  Mary's,  February  20,  1863.) 

Thomas  "W.,  aged  thirty-nine,  a  decorative  painter,  had 
always  enjoyed  robust  health  till  the  4th  of  this  month,  when 
he  was  standing  on  a  ladder  graining  a  shop-front.  Without 
any  warning  or  previous  feeling  of  illness  he  suddenly  lost  his 


THORACIC  ANEURISM.  317 

senses  and  fell  down.  On  coming  to  himself  after  a  few  minutes 
he  found  he  was  not  paralyzed  in  any  part,  but  had  severe  pain 
in  the  side.  This  he  attributed  to  the  fall,  and  thouo'ht  that  he 
had  broken  a  rib.  No  fracture  of  the  bones  however  could  be 
found,  and  the  pain  in  the  side  appears  to  have  been  treated  as 
pleurisy  caused  by  the  injury,  the  most  natural  diagnosis  under 
the  circumstances.  On  his  admission  to  the  hospital  on  the 
11th,  a  week  after  the  accident,  the  whole  of  the  left  side  of  the 
chest  was  dull  on  percussion  before  and  behind,  and  there  was 
entire  absence  of  breathing  except  in  the  two  upper  inches  next 
the  collar-bone,  where  it  was  bronchial,  the  sough  of  expiration 
being  very  prolonged.  There  was  no  pulsation  or  heart  sounds 
perceptible  in  the  cardiac  region,  the  organ  being  pushed  over 
to  the  right  side  beyond  the  median  line.  The  diagnosis  of  the 
medical  man  who  had  previously  seen  him  was  adhered  to  by 
us,  a  blister  was  applied  to  the  left  side,  and  on  the  14th  the 
heart  was  much  nearer  to  its  natural  place  than  before,  and  the 
breathing  in  the  upper  lobe  of  the  left  lung  more  normal.  He 
said  he  had  less  difficulty  in  respiration,  and  no  pain  in  the  side. 
I  still  continued  to  hold  the  original  opinion,  and  supposed  the 
pleuritic  fluid  to  be  in  course  of  absorption. 

He  continued  going  on  well  till  the  night  of  the  15th,  when 
he  suddenly  jumped  up  exclaiming  that  he  was  dying,  put  his 
hand  to  his  side,  fell  back  deadly  pale,  and  soon  ceased  to 
breathe. 

The  post-mortem  examination  which  has  just  now  taken  place, 
has  exphdned  the  mystery.  You  see  here  in  the  descending 
portion  of  the  thoracic  aorta  just  above  the  diaphragm,  the  sac 
of  an  aneurism  large  enough  to  hold  a  man's  fist,  out  of  the  left 
side  of  which  a  smaller  sac  about  as  big  as  a  chestnut  protrudes 
towards  the  left  pleura.  And  in  this  smaller  sac  there  is  a  rent 
a  quarter  of  an  inch  long,  which  allowed  the  blood  to  flow  freely 
out  into  the  cavity  of  the  pleura,  and  to  fill  it  up  with  between 
five  and  six  pints  of  blood.  The  blood  had  so  far  separated  into 
serum  and  coagulum  that  the  fluid  which  first  issued  on  opening 
the  chest  was  about  as  clear  as  that  which  you  find  in  a  bleed- 
ing cup  carefully  put  by  ;  it  was  hardly  at  all  stained  red.  The 
21 


318  THORACIC  ANEURISM. 

heart  was  not  at  all  injured  by  its  dislocation,  though  lying 
entirely  to  the  right  of  the  cardiac  region.  The  left  lung  was 
very  little  pervious  to  air,  being  sodden  and  inelastic  in  tissue. 
The  pleura  was  quite  natural,  showing  no  signs  of  inflammatory 
action. 

I  need  hardly  say  that  no  suspicion  of  the  true  state  of  things 
crossed  anybody's  mind  during  the  patient's  life.  The  mode  of 
death  is  so  rare,  that  if  an  exactly  similar  case  appeared  to- 
morrow while  this  one  was  fresh  in  my  mind,  I  think  I  should 
make  the  diagnosis  I  did  here,  of  a  collection  of  pleuritic  fluid 
from  injury  to  the  pleura  or  lung.  During  the  autopsy  a  pupil 
present,  with  a  juvenile  objection  to  being  wrong  in  a  diagnosis, 
upheld  the  idea  of  its  having  been  originally  a  case  of  serous 
efiusion,  into  which  the  aneurismal  sac  had  burst  at  the  time  of 
death.  Tempting  as  it  is  to  prove  oneself  right  after  all,  I  was 
compelled  to  diifer ;  for  had  such  been  really  the  case  the  bleed 
suddenly  mixed  with  the  previously  collected  fluid  would  have 
stained  it  all  deeply,  and  not  have  been  seen  separated  into 
serum  and  crassamentum,  as  it  was,  on  opening  the  pleura. 

I  feel  sure  that  the  aneurism  first  burst  at  the  time  of  the 
man's  accident.  Then  that  the  prone  posture  and  the  fainting 
allowed  a  fibrinous  plug  to  stay  further  mischief  for  a  time;  and 
that  the  giving  way  of  the  plug  was  the  immediate  cause  of  death. 

This  case  shows  how  imperceptible  and  with  how  little  injury 
to  health  may  be  the  growth  of  a  large  aortic  aneurism — even 
one  extensive  enough  to  have  eroded  the  vertebral  column  as  this 
has  done.  The  patient  did  not  know  w^at  illness  was  till  the 
rupture  took  place.  And  perhaps  that  was  a  consequence  of  the 
fall  in  a  fainting  fit.  Do  not  let  this  discourage  or  terrify  us 
with  the  fear  of  carrying,  without  being  aware  of  it,  such  a  dread- 
ful inmate  in  our  chest.  Let  us  rather  comfort  ourselves  with 
the  assurance,  that  if  it  has  wrought  so  little  harm  when  not 
known  of,  it  may  be  prevented  from  doing  harm  when  it  is  known 
of,  if  prudence  is  used  to  avoid  accidents.  A  clot  inside  this  sac 
would  have  completely  restored  the  form  and  functions  of  the 
aorta. 

Even  with  a  rent  a  quarter  of  an  inch  long  in  it,  you  see  it 


THORACIC  ANEURISM.  •  319 

was  not  necessarily  fatal.  The  patient  lived  nearly  a  fortnight, 
the  blood  first  poured  out  was  beginning  to  be  absorbed,  the 
heart  was  returning  to  its  place,  and  the  lung  to  its  breathing. 
If  we  could  have  seen  what  was  going  on  inside,  there  would 
have  been  nothing  extravagant  in  the  hope  that  a  permanent 
stoppage  of  the  hole  might  have  taken  place;  though,  of  course, 
the  risk  of  the  fatal  accident  which  has  really  happened  would 
have  been  equally  clear  to  us. 


{Clinical,  St.  Marys,  December  12,  1863.) 

Alfred  D.,  a  carpenter,  aged  thirty-three,  enjoyed  general 
good  health  till  three  months  ago,  when  he  became  an  out-patient 
for  a  constant  distressing  cough  and  shortness  of  breath.  This 
state  of  things  became  worse  and  worse,  and  he  was  sent  to  bed 
under  my  care,  November  11  It  was  then  found  that  the  pulse 
in  the  right  wrist  was  very  much  smaller  than  in  the  left,  an 
abnormal  degree  of  pulsation  was  felt  in  the  hollow  above  the 
collar-bone,  and  a  characteristic  whiz,  as  of  an  aneurism,  could 
be  heara  where  the  pulsation  was  strongest.  I  believe  all  who 
examined  him  came  to  the  same  conclusion,  that  there  was  an 
aneurism  of  the  arteria  innominata,  or  at  all  events  involving 
the  arteria  innominata,  and  pressing  upon  the  trachea.  The 
diagnosis  was  too  clear  to  be  of  much  interest.  The  lungs  were 
very  much  congested,  coarse  and  fine  crepitations  being  heard 
in  various  parts,  and  the  finer  crepitations  especially  in  the 
lower  lobes,  of  which  the  right,  on  percussion  beneath  the 
scapula,  was  duller  than  the  left.  The  patient  was  harassed  by 
constant  dyspnoea  and  frequent  cough,  especially  at  night,  and 
had  severe  pain,  sometimes  spasmodically  aggravated,  in  the 
neck  behind  the  right  collar-bone.  There  was  copious  muco- 
purulent expectoration. 

To  relieve  the  afore-mentioned  pain,  general  bleeding  from 
the  left  arm  was  once  resorted  to,  and  several  times  leeches 
were  applied  above  the  clavicle.  The  patient  said  that  the 
leeches  gave  the  most  relief;  an  assertion  different  from  what  I 


320  THORACIC  ANEURISM. 

have  lioard  made  in  otlicr  cases  of  aneurism  of  the  trunk  vessels, 
and  I  am  sorry  to  say  I  cannot  explain  the  discrepancy. 

Digitalis  and  lobelia  were  also  administered  internally,  and 
blisters  and  mustard  poultices  Avere  applied  externally;  but  I 
cannot  say  that  either  gave  any  relief  to  the  cough  or  dyspnoea; 
and  indeed  a  week  before  his  death  they  were  left  off  as  appa- 
rently inefficient  remedies.  Morphia  alone,  and  the  afore-men- 
tioned leeches,  seemed  of  any  advantage. 

A  week  ago  he  had  an  attack  of  haemoptysis;  but  that  was 
arrested  by  leeches,  and  he  went  on  without  much  change,  vary- 
ing in  his  fortune  from  time  to  time,  now  better,  now  worse,  till 
yesterday  In  the  morning  he  told  the  sister  of  the  ward  he 
thought  he  was  really  improved  in  health,  and  that  he  could  lie 
down  easier  in  bed.  But  after  dinner  he  experienced  great  dif- 
ficulty in  breathing,  said  he  felt  he  was  dying,  sent  for  his  wife 
and  mother,  and  became  livid  and  insensible  almost  before  they 
arrived.  To-day  you  are  going  to  see  the  post  mortem  exami- 
nation. 

[Extract  from  record  of  post-mortevi  examination  by  Mr. 
Nayler,  curator  to  St.  Mary's  Hospital  Museum: — "The  aorta 
in  its  ascending  and  transverse  portions  was  greatly  dilated, 
and  involved  the  origin  of  the  innominata  artery.  Its  coats  felt 
also  somewhat  hard  and  brittle.  In  consequence  of  its  increased 
size,  the  aorta  rose  much  higher  than  natural  in  the  chest,  and 
obscured  the  root  of  the  innominata.  On  laying  open  the  trachea, 
its  upper  part  was  found  to  be  healthy,  but  in  its  lower  half  the 
mucous  membrane  was  much  congested,  and  its  rings  flattened, 
and  at  this  point  they  appeared  to  have  undergone  partial  ab- 
sorption. The  heart  was  soft  and  thin.  The  lungs  were  very 
full  of  blood,  and  at  the  back  part  were  not  universally  crepi- 
tant."] 

The  cause  of  death  doubtless  was  a  sudden  increase  of  the 
congestion  of  the  lungs  from  the  interference  of  the  dilated 
artery  with  the  pneumogastric  nerve,  perhaps  especially  with 
the  recurrent  branch.  Probably  the  only  chance  of  relief  for 
him  would  have  been  a  recurrence  of  the  hemoptysis  which  was 
of  use  a  week  ago.     I  should  have  practised  bleeding  and  leech- 


THORACIC  ANEURISM.  321 

ing  more  assiduously,  had  not  the  weakly  pulsation  of  the  heart 
given  a  warning  against  it,  and  made  one  doubt  if  life  would  be 
prolonged  by  that  expedient,  while  complete  renewal  or  cure 
was  out  of  the  question. 

Do  not  set  down  loss  of  blood  as  a  mere  destructive  agency, 
pure  and  simple.  The  more  perfect  and  accurately  graduated 
form  of  it  exhibited  in  haemoptysis,  and  our  rough  imitations 
with  lancets  and  leeches,  by  relieving  the  congested  lungs  of  a 
burden  that  impedes  their  functions,  cause  more  new  blood  to 
be  made  than  heretofore,  and  so  are  an  indirect  renewal  of  life. 

You  may  observe  that  this  man  has  had  a  considerable  amount 
of  digitalis,  and  that  no  beneficial  result  has  been  apparently 
produced  by  it.  I  must  therefore  say  something  justificatory  of 
myself  for  administering  it.  My  reason  is,  that  digitalis  seems 
to  me  to  exert  a  special  influence  over  involuntary  muscular 
fiber,  causing  its  contraction  to  be  more  firm  and  powerful;  and 
that  it  exerts  this  influence  most  especially  when  the  muscular 
fiber  is  abnormally  lax,  or  when  it  is  degenerated.  Cats  killed 
during  the  action  of  digitalis  were  found  by  Dr.  Handfield  Jones, 
in  experiments  he  made  some  years  ago,  to  have  the  heart 
strongly'-  contracted.  In  the  human  subject  I  have,  ever  since  I 
have  been  physician  to  St.  Mary's  hardly  ever  omitted  to  give 
digitalis  to  cases  of  thin  dilated  heart,  with  irregular  failing 
pulse ;  and  the  general  result  you  have  often  seen  to  be,  that  the 
pulse  grows  firm  and  regular.  Digitalis  acts  also  upon  the  in- 
voluntary fibers  of  the  uterus,  renewing  their  tone,  bracing  them 
up,  and  stopping  the  monorrhagia  of  relaxation.  You  have  several 
times  had  an  opportunity  of  seeing  monorrhagia  stayed  in  this 
way,  and  notably  one  case  admitted  under  my  care  rather  more 
than  a  fortnight  ago,  which  I  especially  mention  now  because 
other  involuntary  fibers  besides  those  of  the  uterus  were  influenced. 

Emily  T.,  a  quadroon  nursery-maid,  aged  seventeen,  was  ad- 
mitted November  27,  suff"ering  from  monorrhagia,  which  iiad  been 
almost  constant  for  about  three  months,  and  had  forced  her  to 
give  up  her  situation.  The  quantity  of  blood  lost  was  not  large 
at  any  one  time,  but  there  was  a  continuous  drain  which  had 
weakened  her  very  much  and  rendered  her  very  anoemic.     Her 


322  THORACIC  ANEURISM. 

mother,  a  tall  and  stout  mulatto,  stated  that  the  disease  was 
hereditary,  she  having  herself  been  often  laid  up  in  the  same 
way  when  a  young  woman.  The  girl's  uterus  comes  down  very 
low  in  the  vagina,  almost  to  the  hymen,  and  the  os  uteri  is  soft, 
tumid,  and  painful.  There  is  also  pain  on  pressing  the  region 
of  the  ovaries.  She  stated  in  addition,  and  the  statement  was 
confirmed  by  her  mother,  that  from  childhood  she  had  been 
afflicted  with  incontinence  of  urine,  and  never  remembered  to 
have  passed  a  night  without  wetting  her  bed.  Infusion  of  digi- 
talis was  prescribed  for  the  menorrhagia,  and  the  dose  gradually 
increased  up  to  two  ounces  every  three  hours.  At  this  point  the 
medicine  was  left  off,  for  nausea  and  faintness  with  loss  of  appe- 
tite were  induced,  and  the  sanguineous  discharge  ceased.  It  has 
since  returned  once  for  a  few  hours,  but  was  immediately  checked 
by  a  resumption  of  the  digitalis.  So  far  the  course  of  events 
was  the  usual  and  expected  course;  but  the  next  observed  phe- 
nomena is  to  me  at  least  new;  the  patient  states  that  the  incon- 
tinence of  urine  has  quite  disappeared  since  the  night  before  the 
arrest  of  the  menorrhagia,  that  for  the  first  time  within  her 
memory  she  has  been  able  to  hold  her  water  during  sleep,  and 
now  has  not  wetted  her  bed  for  ten  nights. 

The  beneficial  action  of  digitalis  over  the  sphincter  of  the 
bladder  is  of  a  piece  with  its  action  over  the  uterus,  and  is  truly 
not  surprising.  I  was  not  aware  of  it  before,  but  shall  certainly 
test  it  again,  both  in  this  girl  in  case  of  a  return,  and  in  other 
instances  of  that  most  unmanageable  disease,  incontinence  of 
urine  in  the  female. 

This  digression  is  for  the  purpose  of  excusing  my  hope  that 
digitalis  might  prove  of  use  to  the  dilated  and  relaxed  muscular 
fibers  of  arteries.  The  hope  may  be  grounded  on  imperfect 
knowledge,  and  was  disappointed  in  this  instance ;  but  it  is  not 
an  utterly  irrational  one,  not  a  mere  excursion  into  the  realms 
of  empiricism. 

[I  feel  it  a  duty  to  add  a  few  sentences  in  this  edition  as  to 
the  future  conduct  of  those  who  have  suffered  from  external 
aneurism,  and  in  whom,  of  course,  a  recurrence  of  the  disease  in 
more  important  parts  is  to  be  feared.     It  is  obvious  that  the 


THORACIC  ANEURISM.  323 

case  is  here  quite  different  from  that  of  curing  aueurism.  The 
method  of  starvation  and  bleeding  recommended  in  the  lecture 
would  be  most  injurious,  as  tending  to  induce  further  debility 
and  degeneration.  It  should  be  used  for  the  purpose  of  inducing 
the  formation  of  clot  only.  The  prevention  of  further  degenera- 
tion of  the  arteries  must  be  conducted  on  quite  an  opposite 
principle.  Iron,  nutritious  food,  and  everything  that  promotes 
vigorous  vitality,  should  be  perseveringly  given  for  the  rest  of 
the  patient's  life.  I  would  strongly  urge  also  a  change  from 
the  climate  of  England,  where  degenerative  disease  is  the  rule 
and  acute  disease  the  exception,  to  Italy,  where  degenerative 
disease  is  the  exception  and  acute  disease  the  rule — a  change,  if 
not  for  life,  at  all  events  for  long  enough  to  alter  the  constitu- 
tion. It  may  be  remarked  that  it  is  especially  in  the  absence 
of  aneurism  that  this  peculiarity  of  the  Italian  climate  is  shown. 
In  the  statistics  of  Milan  Hospital  {Rendiconto  della  Benificenza 
delV  Ospetale  Maggiore,  Sj-c,  1862),  I  find  but  4  cases  of  thoracic 
aneurism  in  61,761  patients,  or  1  in  15,440 ;  whereas  at  St. 
Mary's  Hospital,  London,  I  find  29  cases  in  7319  patients,  or 
1  in  252.  Again,  at  Genoa  I  find  the  last  published  bills  of 
mortality  (for  1860,  printed  by  Dr.  Giovanni  du  Jardin)  with- 
out any  deaths  by  aneurism.  The  last  published  for  London 
contains  103.] 


LECTURE   XXV. 
DISEASE   OF   HEART. 

Part  1. — Comparison  of  injury  io  life  from  the  two  sets  of  valves, 
severally — Deductions  from  autopsies — Case  in  point — Treat- 
metit  calmative  and  restorative.  Second  case — Diseased  mitral 
and  aortic  valves  with  dilated  parietes — Treatment  similar  to 
last  case,  with  certain  additions. 

Part  2. — Degree  of  importance  to  he  attached  to  the  different 
points  ascertainable  by  auscultatory  diagnosis — Consequences 
of  valvular  disease  different  in  different  classes  of  life — Cases 
in  illustration  of  its  effects  in  tlie  upper  classes  as  distinguished 
from  hospital  patients — Causes  of  difference — Treatment  of 
patients  ivith  disorganized  valves — Avoidance  of  dangers — 
Iron — Chloride  of  Sodium — Hydrochloric  Acid — Abuse  of 
alcohol — Danger  of  rupture  of  valves — Case — Angina  pectoris 
— Pathology  of  dilatation — Explanations  to  patients — All 
diseases  of  heart  to  he  viewed  practically  as  one. 

{Clinical,  St.  Marys,  December  20,  1861.) 

In  speaking  of  diseases  of  the  cardiac  valves  I  practically  in- 
tend what  is  said  to  apply  only  to  those  of  the  left  side  of  the 
heart;  for  the  tricuspid  and  pulmonary  are  seldom  affected  alone 
with  such  severity  as  to  produce  either  symptoms  during  life, 
or  lesions  recognizable  after  death ;  so  that  physicians  know  very 
little  about  them.  It  is  the  mitral  and  aortic  valves  whose  alter- 
ations we  are  best  able  to  recognize  by  physical  signs,  and 
whose  defects  cause  injury  to  the  muscular  walls  of  the  heart. 
They  are  a  source  of  anxiety  to  us  in  our  daily  duty,  whereas 
the  others  are  rather  a  matter  of  curiosity. 

Comparing   the   different  valvular  lesions  of  the   left  heart, 


DISEASE  OF  HEART.  325 

with  regard  to  the  injury  they  inflict,  and  the  consequent  pro- 
portionate goodness  or  badness  of  the  prognosis  to  be  formed,  I 
find  that  the  worst  cases,  that  is,  the  most  liable  to  have  serious 
consequences,  are  those  in  which  both  the  aortic  and  mitral 
valves  are  simultaneously  imperfect;  the  next  worst  are  those 
in  which  the  aortic  have  suffered ;  and  the  most  favorable  are 
those  where  the  mitral  alone  are  inefficient. 

Thus  I  find  that  in  115  cases  recorded  in  the  "post-mortem 
book"  at  St.  George's  Hospital  from  1840  to  1850,  wliere  dis- 
ease of  one  set  of  valves  was  accompanied  by  alteration  in  the 
cardiac  walls,  the  aortic  valves  alone  were  diseased  in  G4,  the 
mitral  valves  alone  in  51.  And  in  the  former  case  also  the 
alteration  had  assumed  a  more  marked  character ;  for  in  cases 
where  the  aortic  valves  alone  were  diseased,  the  size  of  the  cavi- 
ties was  disproportionally  large  in  comparison  with  the  enlarged 
walls  in  36;  whereas  when  the  mitral  valves  alone  were  diseased, 
the  disproportionate  enlargement  occurred  in  only  18.  And  this 
diff'erence,  it  is  to  be  observed,  is  not  dependent  on  the  greater 
frequency  of  lesions  of  the  aortic  valves  alone,  for  in  point  of 
fact  they  are  not  more  frequent.  Thus  in  hearts  whose  walls 
were  still  normal,  there  was  more  or  less  lesion  of  the  mitral 
valve  in  34,  of  the  aortic  in  30. 

The  powerful  influence  of  the  double  lesion  (/.  e.  of  both 
valves  at  once)  is  shown  by  its  being  found  with  healthy  heart- 
walls  in  only  6. 

Now  this  diseased  state  of  the  heart's  walls  is  so  very  much 
the  most  important,  and  so  very  much  the  most  frequent  of  the 
evil  consequences  of  disorganized  valves,  that  practically  speak- 
ing it  may  be  taken  to  represent  the  whole  of  those  consequences. 
All  our  calculations  of  prognosis  in  cases  of  valvular  injury  need 
have  reference  to  it  alone. 

I  have  been  hitherto  quoting  from  my  systematic  lectures  on 
the  practice  of  medicine,  apropos  of  a  prognosis  I  have  given  of 
a  case  now  under  your  eyes,  and  which  I  have  selected  as  one 
promising  enough  to  use  as  an  illustration  of  treatment. 

A,  J.,  aged  thirteen,  had  rheumatic  fever  three  years  ago  at 
Brighton,  of  which  illness  she  has  not  much  recollection,  but 


326  DISEASE  OF  HEART. 

she  shows  marks  on  the  cardiac  region  of  leeches,  probably 
applied  at  that  time  for  inflammation  of  the  heart.  She  has 
since  then  always  suffered  from  palpitation  on  the  slightest 
exertion,  or  on  any  emotion ;  and  she  has  dyspnoea  on  attempt- 
ing to  go  up  stairs  or  up  hill,  or  walk  above  her  usual  pace. 
She  had  an  attack  of  spitting  of  blood  eighteen  months  ago,  but 
otherwise  her  health  has  been  good.  Her  complexion  and  ap- 
pearance fully  bear  out  this  statement;  she  is  fresh-colored, 
muscular,  bright-eyed,  and  plump;  her  mind  is  active  and  intel- 
ligent, and  though  the  mammae  are  infantile  and  the  catamenia 
have  not  appeared,  she  has  the  air  and  appearance  of  a  girl  two 
years  older  than  her  real  age.  I  may  remark  in  passing  that 
such  a  backward  development  of  the  reproductive  organs  as  you 
here  see  is  a  very  common  effect  of  cardiac  disease  in  both  sexes. 
The  growth  of  the  other  organs  or  functions,  mental  or  bodily, 
does  not  seem  to  be  retarded. 

The  palpitations  have  lately  been  rather  more  troublesome  than 
usual,  and  on  examination  of  the  chest  they  are  explained  by  a 
vibrating  tremor,  sensible  to  the  finger,  at  the  apex  of  the  heart, 
and  at  the  same  point  a  very  loud  systolic  murmur.  The  second 
sound  is  loud  and  sharp.  The  interval  is  clear.  The  systolic 
murmur  is  heard  only  very  indistinctly  at  the  base  of  the  heart. 
On  admission  the  pulse  and  heart-stroke  were  uneven  in  strength, 
but  have  by  rest  in  bed  become  nearly  natural. 

On  percussion  the  dullness  of  the  cardiac  region  does  not 
appear  to  extend  beyond  the  breadth  and  height  which  is  usual 
in  the  normal  state. 

This  girl  appears  to  labor  under  lesion  of  the  mitral,  with 
healthy  aortic  valve,  one  of  the  varieties  of  cardiac  injury  the 
least  likely  to  cause  enlargement,  and  therefore  the  least  inju- 
rious of  any;  and  since  I  cannot  find  that  the  heart  is  as  yet 
enlarged,  let  us  give  her  the  benefit  of  the  doubt,  and  hope  that 
it  may  not  become  so. 

In  the  treatment,  the  first  object  is  to  restore  regularity  and 
calmness  to  the  affected  organ.  With  that  view  she  has  been 
kept  lying  down  for  a  week ;  she  has  had  once  two  leeches  and 
once  one  leech  applied  beneath  the  left  breast,  and  has  taken  five 


DISEASE  OF  HEART.  327 

minims  of  tincture  of  digitalis  three  times  a  day.  This  has  been 
so  far  effectual,  and  will  be  continued  only  a  short  time  longer. 

The  next  object  is  to  keep  the  blood  in  as  rich  and  nutritious 
a  state  as  possible.  The  child  has  a  critical  period  of  her  life  to 
go  through  sooner  or  later,  the  time  of  puberty,  when  there  is  a 
call  upon  all  the  powers  of  growth.  If  she  gets  anaemic  then, 
the  heart  will  but  too  surely  enlarge  by  dilatation.  I  have  begun 
therefore  giving  her  iron  from  the  first,  and  shall  urge  its  con- 
tinuance as  long  as  I  can  keep  sight  of  her. 

The  richness  of  the  blood  instead  of  increasing  the  chance  of 
haemoptysis,  as  you  might  have  imagined,  diminishes  it.  Thin 
watery  blood  easier  oozes  out ;  and  besides,  the  more  nutritive 
the  circulating  fluids,  the  more  active  is  the  heart,  the  better  it 
empties  itself,  and  the  less  is  the  blood  kept  back  in  the  lungs. 

Another  case  in  the  same  ward  is  not  quite  such  a  hopeful  one. 
Mary  K.,  aged  twenty-two,  single,  has  been  here  since  Novem- 
ber 25.  She  says  that  she  has  had  rheumatic  fever  once  this 
time  seven  years.  She  had  no  pain  in  the  chest  then,  and  per- 
fectly recovered,  remaining  well  till  an  attack  of  what  she  calls 
"bronchitis,"  three  years  ago.  After  this  again  she  was  quite 
well  till  two  years  since,  when  she  began  to  sufier  from  severe 
pain  in  the  cardiac  region,  and  had  frequent  colds.  She  also 
frequently  had  bleeding  at  the  nose,  and  spitting  of  blood,  even 
when  keeping  quiet,  and  when  she  moved  about  experienced 
much  dyspnoea  and  palpitation  of  the  heart.  She  however 
continued  in  service,  and  did  her  work.  Six  weeks  before  admis- 
sion she  observed  that  she  got  blue  in  the  face,  and  suffered  more 
than  usual  from  dyspnoea,  so  that  three  weeks  before  she  was 
obliged  to  give  up  work. 

When  you  first  saw  her  she  was  very  blue  in  the  face,  and 
could  hardly  get  her  breath  ;  she  was  spitting  blood,  and  there 
were  loud  sibilant  and  crepitant  rales  all  over  the  lungs,  without 
any  localized  dullness  on  percussion  in  the  pulmonary  regions. 
The  pulse  was  very  irregular  and  intermittent.  The  cardiac 
region  was  dull  on  percussion  up  to  the  interval  above  the  third 
rib,  and  as  far  as  the  sternum  towards  the  right  side.  The  second 
sound  of  the  heart  was  scarcely  to  be  heard  at  all,  but  was  re- 


328  DISEASE  OF  HEART. 

placed  by  no  murmur.  There  was  a  loud  systolic  murmur, 
loudest  at  the  apex,  and  followed  by  a  peculiar  chirping  sound, 
ratlier  anterior  to  the  time  of  the  second  sound.  The  intervals 
were  imperfectly  marked. 

In  Mary  K.  there  is  probably  regurgitation  through  both 
aortic  and  mitral  valves.  What  she  has  suffered  from  is  obstruc- 
tion to  the  passage  of  blood  through  the  lungs,  and  consequently 
non-aeration  and  venosity.  She  had  some  haemoptysis,  which 
gave  relief,  so  I  took  the  hint,  and  cupped  her,  and  put  on  some 
leeches  several  times,  which  have  also  given  relief.  The  irregu- 
larity and  excitabilit}^  of  the  pulse  have  been  successfully  treated 
by  digitalis. 

The  venosity  of  the  blood  is  in  great  danger  of  being  suc- 
ceeded by  ancemia,  especially  as  her  appetite  is  very  deficient. 
The  heart  is  already  enlarged,  and  I  fear  it  is  improbable  that 
she  will  ever  be  able  to  get  her  own  living  again  ;  still  I  think  it 
right  to  give  her  iron,  and  purpose  to  continue  it  as  long  as  pos- 
sible, that  at  all  events  she  may  obtain  all  the  advantage  she  is 
capable  of  receiving.  The  most  unhappy  event  for  her  would 
be  degeneration  of  the  muscular  walls  of  the  affected  viscus,  so 
that  they  should  fail  from  debility  duly  to  circulate  its  contents  ; 
and  I  believe  the  best  chance  of  avoiding  this  degeneration  lies 
in  keeping  up  the  supply  of  a  really  nutritious  blood. 

You  may  observe  that  the  digitalis  was  left  off  several  times. 
This  was  not  on  account  of  its  failing  in  its  object  of  calming 
and  reducing  to  regularity  the  irregular  heart,  for  that  it  effects 
well ;  but,  because  when  given  in  larger  doses  than  five  minims 
of  the  tincture,  it  produced  nausea,  and  prevented  her  taking  her 
meals.  Now  the  physic  we  order  on  the  diet  card  is  at  least 
equally  important  with  that  on  the  medicine  card,  and  you  must 
be  careful  where  you  want  to  renew  life  not  to  diminish  the 
means  of  that  renewal.  The  production  of  nausea  and  loss  of 
appetite  Avould  do  more  harm  than  any  action  of  the  medicine 
could  do  good. 


DISEASE  OF  HEART.  329 

(Clinical,  St.  Mary's,  December  6,  1861,  with  additions  in  sub- 
sequent years.) 

There  are  always  in  our  wards  a  few  chronically  diseased 
hearts,  and  I  very  weldora  walk  round  without  calling  your 
attention  to  one  or  two  as  studies  of  diagnosis. 

I  notice  that  when  you  begin  the  physical  examination  of  the 
patient  whom  you  know  to  have  a  cardiac  complaint,  you  search 
first  and  foremost  for  endocardial  murmurs,  and  then  you  often 
rest  from  your  labor,  and  say  what  you  have  found.  You  seem 
to  consider  that  sign  as  the  most  essential  part  of  the  diagnosis. 
You  are  partly  right  and  partly  wrong. 

This  knowledge  doubles  the  value  of  other  future  observations 
about  the  heart ;  but  standing  alone,  it  is  of  less  importance  than 
any  of  them.  While,  then,  I  willingly  receive  this  report  first, 
I  always  beg  you  to  go  on  without  delay  to  further  observations. 

The  importance  of  the  existence  or  non-existence  of  valvular 
disease  lies  not  in  the  injui-y  it  inflicts  itself,  as  in  the  likelihood 
of  the  induction  of  the  other  lesions  of  the  heart.  If  the  mus- 
cular structure  remains  healthy,  injured  valves  do  not  appear 
capable  of  causing  death.  But  very  surely  are  they  fatal  when 
they  are  folloAved  by  dilatation  or  thickening  or  degeneration  of 
the  cardiac  walls,  with  their  sad  train  of  dropsies,  apoplexy, 
pulmonary  hemorrhage,  &;c. 

In  the  2a.61  post  mortem  examinations  at  St.  George's  Hos- 
pital in  ten  years,  the  cardiac  valves  were  diseased  Avithout  the 
walls  of  the  heart  being  affected  113  times;  but  in  every  case 
there  were  other  lesions  amply  sufficient  to  account  for  death 
quite  independent  of  the  valves,  such  as  accidents,  surgical  com- 
plaints, cancer,  low  fever,  &c.  In  one  alone,  where  anasarca 
from  granular  kidneys  was  the  immediate  cause  of  death,  could 
any  symptom  be  debited  to  diseased  valves  with  healthy  heart, 
and  that  symptom  was  pulmonary  hemorrhage.* 

In  the  classes  of  people  represented  by  hospital  patients,  the 
probability  that  valvular  disease  will  be  followed  by  its  unhappy 

*  "  Decennium  Pathologicum,"  chap,  x,  sect.  i. 


330  DISEASE  OF  HEART. 

consequences  is  very  great.  When  a  patient  thus  affected  leaves 
the  wards,  you  may  expect  to  see  him  again  shortly,  and  on  each 
fresh  admission  with  a  more  severe  complaint.  Hence  the  more 
attentive  students  you  are  the  worst  prognosis  do  you  justifiably 
form.  But  you  must  not  apply  the  same  rule  to  the  different 
grade  of  society  among  whom  you  hope  your  private  practice 
will  lie.  AVith  persons  in  easy  circumstances  valvular  lesions 
exist  for  years  and  years,  perhaps  through  the  greater  part  of  a 
long  life,  and  not  only  not  prove  fatal,  but  may  fail  even  to 
cause  symptoms  bad  enough  to  make  them  consult  a  medical 
practitioner. 

To  prove  to  you  this  fact,  I  will  quote  from  my  private  notes 
some  cases  of  persons  in  easy  circumstances  in  whom  the  stetho- 
scope or  the  history,  or  both,  gave  every  indication  of  injury  to 
the  valves  of  long  standing,  but  in  whom  no  inconvenience  suflfi- 
cient  to  be  called  illness  by  themselves  has  followed. 

Defective  valves  of  57  years'  standing. — Col.  R.  S.,  at  eight 
years  old,  had  a  bad  attack  of  rheumatic  fever,  which  laid  him 
up  for  eleven  months,  and  from  which  his  heart  has  never  wholly 
recovered.  At  sixty-five  years  of  age  he  had  a  very  loud  mur- 
mur with  the  first  sound.  The  year  before  he  had  had  an  attack 
of  inflammation  (congestion  ?)  of  the  lungs,  which  had  left  a  con- 
siderable portion  of  the  pulmonary  tissue  impervious,  for  his  vital 
capacity,  tested  by  the  spirometer,  was  only  150  cubic  inches, 
his  height  being  5  feet  10^  inches. 

Defective  valves  of  50  years'  standing. — Archdeacon  B.,  at  six 
years  of  age,  had  an  attack  of  inflammation  of  the  heart,  and 
since  that  time  has  been  subject  to  irregular  action  of  the  organ, 
often  followed  by  fainting  fits.  He  has  for  some  years  lived  more 
generously  than  he  used  to  do,  and  suffers  much  less  inconve- 
nience. The  action  of  the  heart  is  irregular  and  uneven,  and 
there  is  a  murmur  with  the  first  sound.  He  is  now  fifty-six,  well, 
and  moderately  active.     (Dec.  1861.) 

Defective  valves  of  ^^y ears  standing. — C.  B.,  at  twenty-eight, 
had  rheumatic  fever  from  sleeping  in  a  damp  bed.  At  sixty- 
three  years  old  (in  1852)  he  had  marked  systolic  murmur  at 
the  apex  of  the  heart,  but  considered  himself  quite  well,  and  is 


DISEASE  OF  HEART.  331 

alive  now  (1861)  when  he  must  have  long  passed  his  threescore 
years  and  ten. 

Defective  valves  of  27  years'  standing. — T.  H.  G.,  at  six  years 
old,  had  rheumatic  fever.  Since  then  he  has  had  no  illness  of 
any  kind.  In  June,  1860,  when  he  was  thirty-two,  I  detected 
a  loud  whizzing  murmur  with  the  first  sound;  in  July,  1861,  the 
same  murmur  remained.  He  is  alive  and  I  believe  well  now. 
(Dec.  1861.) 

Defective  valves  of  about  21  years'  standing. — C.  S.,  aged 
thirty-six,  in  1855  had  a  low  blowing  mitral  murmur.  He  used 
to  have  severe  palpitations  when  an  under-graduate  at  Cam- 
bridge ;  he  has  enjoyed  average  health  since,  with  the  exception 
of  what  he  calls  "  colds,"  that  is,  a  feeling  of  general  malaise, 
for  which  he  takes  tonics,  and  is  always  better  for  the  practice. 
He  is  alive  and  well  now  in  1862. 

Defective  valves  of  15  years'  standing. — E,  G.,  in  1846  had 
inflammation  of  the  chest,  accompanied  by  severe  pain  in  the 
heart.  I  saw  him  first  in  June,  1848,  when  there  was  a  loud 
musical  murmur  with  the  first  sound.  In  December,  1848,  and 
in  January,  1850,  the  same  murmur  remained.  He  is  still  alive 
in  1862,  aged  seventy-two. 

Defective  valves  of  at  least  11  years'  standing. — R.  H.,  who 
in  1861  was  still  alive  and  forty-two  years  of  age,  had  in  1850  a 
blowing  systolic  mitral  murmur. 

Defective  valves  of  at  least  7  years'  standing. — R.  A.  A.,  in 
1862  still  alive,  aged  fifty-three,  had  a  blowing  systolic  murmur 
when  I  saw  him  in  1854.  He  is  a  robust  muscular  man,  in  the 
habit  when  young  of  pulling  in  boat  races,  to  which  he  attributes 
the  palpitations  he  now  occasionally  suffers  from. 

Defective  valves  of  7  years'  standing — T.  J.,  aged  twenty-three 
in  1854,  had  undergone  scarlatina  at  sixteen  years  old,  and  never 
any  other  illness.  I  could  hear  a  blowing  systolic  murmur  at 
the  apex  of  the  heart,  and  he  had  pain  in  the  cardiac  region  after 
exertion,  but  was  not  otherwise  ill.  His  subsequent  history  is 
unknown  to  me. 

Defective  valves  of  7  years'  standing. — D.  F.,  aged  twenty- 
nine  in  1852,  also  had  scarlatina  at   twenty -two  years  of  age, 


332  DISEASE  OF  HEART. 

accompanied  by  pain  in  the  heart,  and  followed  by  palpitations 
of  six  weeks'  duration.  There  was  with  some  beats  a  systolic 
murmur  loudest  at  the  apex  at  that  period,  which  was  seven 
years  after  the  reported  cardiac  affection.  His  subsequent  his- 
tory is  also  unknown  to  me. 

Defective  valves  of  7  years'  standing. — Miss  S.  had  rheumatic 
fever  from  sleeping  in  a  damp  bed,  accompanied  by  pain  in  the 
cardiac  region,  in  1856,  when  she  was  twenty-three  years  old. 
There  is  a  distinct  very  localized  systolic  murmur  at  the  level  of 
the  aortic  valves.  She  has  attacks  of  angina  pectoris  from  ex- 
posure to  cold,  but  with  care  is  able  to  live  like  other  people. 
Between  April,  1862,  and  July,  1863,  she  lost  no  ground,  and 
had  only  two  slight  attacks  of  angina  pectoris. 

Defective  valves  of  at  least  b  years'  standing. — F.  J,,  aged 
thirty  in  1856,  had  then  an  irregular  pulse  and  a  systolic  mur- 
mur, without  any  dyspnoea  or  general  symptoms  arising  from  the 
imperfection  of  the  heart.     He  is  alive  now  (Dec.  1862). 

Defective  valves  of  18  months'  standing. — A.  D.,  aged  forty- 
three  in  1850,  had  had  rheumatic  fever  eighteen  months  pre- 
viously. The  heart's  action  was  irregular,  and  there  was  a  systolic 
murmur,  but  no  general  symptoms  at  all  referable  to  cardiac  dis- 
ease, nor  any  suspicion  that  cardiac  disease  existed. 

Defective  valves  of  a  years  standing. — W.  II.  C,  aged  thirty- 
one  in  1850,  had  had  rheumatic  fever  a  year  before,  with  inflam- 
mation of  the  heart,  but  considered  that  he  had  quite  recovered ; 
and  he  really  seemed  to  have  done  so,  for  his  vital  capacity  was 
220  cubic  inches,  his  height  being  5  feet  9  inches,  so  that  there 
was  no  pulmonary  obstruction.  There  was  a  systolic  murmur, 
loudest  at  the  level  of  the  aortic  valves. 

Defective  valves  of  unknotvn  duration,  but  at  the  date  of  exami- 
nation without  any  deleterious  effect  on  the  general  health. — J.  P., 
aged  thirty  in  1854,  had  an  intermittent  pulse,  with  a  systolic 
murmur  loudest  at  the  base  and  middle  of  the  heart.  Unusual 
exposure  affected  his  chest  so  as  to  lay  him  up  Avith  cough,  but 
his  general  health  was  good. 

G.  P.,  aged  twenty-six  in  1856,  had  a  very  irregular,  unequal, 
and  intermittent  pulse,  accompanied  by  a  systolic  murmur.  He 
never  suff"ered  from  palpitation,  cough,  or  any  illness  at  all. 


DISEASE  OF  HEART.  833 

F.  D.,  aged  forty-nine  in  1857,  had  a  sawing  systolic  murmur, 
but  had  never  had  any  illness  or  inconvenience  referable  to  the 
heart. 

J.  B.,  aged  forty-eight  in  1856,  had  an  intermittent  pulse,  and 
a  blowing  murmur  with  first  sound  most  distinct  at  the  base  of 
heart.     He  never  suffered  from  palpitations. 

The  subsequent  history  of  these  last  six  cases,  having  been 
only  examined  for  insurance  and  not  further  traced,  is  unknown 
to  me. 

Irregular  pulse  of  long  standing  ivithout  date. — Lord , 

aged  seventy-four  in  1862,  and  alive  now,  with  a  soft  systolic 
murmur  to  be  heard  at  the  apex  of  the  heart,  has  a  distinct  re- 
collection of  having  an  irregular  pulse  as  long  as  he  can  remem- 
ber anything.  And  other  old  people  have  told  me  the  same, 
though  I  have  not  kept  a  note  of  their  cases. 

Injure/  to  heart  from  rheumatic  fever  of  10  years'  standing. — 
T.  A.  0.,  aged  fifty-one  in  1855,  had  had  rheumatic  fever  ten 
years  previously,  and  since  then  frequent  "  fainting  fits"  and 
palpitations.  The  action  of  the  heart  is  jarring,  and  there  is 
extended  dullness  on  percussion,  but  no  evidence  of  valvular  dis- 
ease.    He  does  not  get  worse. 

You  know  very  well  that  cases  like  these  are  not  to  be  met 
with  in  hospital  practice,  or  among  the  paupers  in  a  woi-khouse. 
Wherein  lies  the  difference  ?  It  is  discoverable  generally  from 
the  histories  which  these  poor  people  tell  of  the  final  breakdown. 
The  tale  usuallj  runs,  "  I  was  pretty  well,  or  only  a  little  short- 
winded,  till  I  was  thrown  out  of  work  and  had  to  live  low;  then 
my  heart  got  to  beat  worse,  and  my  feet  swelled."  Or,  "  1  could 
always  earn  my  living  till  I  was  over-worked  last  summer;"  or, 
"  till  I  caught  a  bad  cold  last  winter ;"  or,  "  till  I  had  sit  up  with 
my  mother  who  died,"  and  so  on.  And  from  this  breakdown 
they  never  get  quite  up  again,  they  never  regain  lost  ground. 
In  short,  you  will  see  that  injured  valves  are  slow  to  lead  to  fur- 
ther cardiac  lesion  in  the  w^ell-nourished,  and  quick  to  lead  to 
further  lesion  in  the  ill-nourished ;  and  that  the  motive  cause  of 
their  evil  effects  is  anaemia,  exhaustion,  debility. 

Do  not  look  upon  this  disadvantage  of  the  poor  in  respect  of 
22 


334  DISEASE  OF  HEART. 

cardiac  disease  as  merely  a  universal  rule  in  all  diseases.  In  a 
good  many  cases  the  poor  recover  easier  than  the  wealthy,  and 
the  good  prognosis  which  you  have  habitually  attached  to  certain 
morbid  states  in  hospital  practice  will  not  be  justified  in  private. 
Continued  fever,  to  wit,  is  less  fatal  in  the  lower  classes,  although 
more  common;  consumption  is  less  frequently  "galloping,"  it 
is  more  chronic,  and  more  rapidly  benefited  in  their  case ;  again, 
anaemia  is  more  often  found  dependent  on  removable  causes,  and 
therefore  quicker  cured  in  cofttagcs  than  in  palaces. 

The  peculiarly  fatal  nature  of  valvular  disease  of  the  heart, 
among  those  who  live  by  bodily  labor,  arises  from  the  fact  just 
mentioned  of  lost  ground  being  never  recovered  from.  The  heart 
is  (physiologically  speaking)  a  single  organ  with  the  single  me- 
chanical function  of  forwarding  the  blood,  and  consisting  of  a 
number  of  unique  parts  mutually  dependent  on  one  another.  If 
the  left  ventricular  valves  are  injured,  the  right  cannot  take 
their  office,  nor  the  aortic  replace  the  pulmonary.  It  is  a  chain, 
proverbially  never  stronger  than  its  weakest  link.  Therefore  no 
relief  can  be  given  to  a  failing  part  by  another  part  taking  its 
duty  ;  no  rest  for  the  purposes  of  recovery  can  be  taken.  The 
Designer  of  our  frames  has  been  here  peculiarly  sparing  of  re- 
serve function.  Such  is  not  the  case  in  other  organs ;  if  one 
kidney  is  destroyed,  the  other  supplies  its  place,  and  as  much 
urea  is  excreted  as  before ;  large  portions  of  lung  may  be  im- 
pervious from  tubercle,  yet  the  blood  be  aerated  normally  by  the 
remainder,  and  the  patient  recover  of  consumption.  But  in  the 
heart  each  successive  little  injury  can  never  be  compensated  for, 
and  is  added  in  turn  to  the  previous  list.  The  wealthier  classes 
can  avoid  all  the  many  circumstances  which  produce  these  suc- 
cessive little  injuries — cold,  want  of  food,  over-exertion,  mental 
worry  ;  and  so  under  good  advice  can  keep  their  imperfect  valves 
from  getting  worse ;  but  those  who  depend  upon  daily  toil  for 
•daily  bread  run  the  risk  and  suffer  the  unhappy  results. 

I  said  early  in  the  lecture  that  I  did  not  blame  you  for  begin- 
ning your  investigation  with  listening  for  cardiac  murmurs,  but 
I  do  blame  you  very  much  if  you  stop  there.  The  evil  import 
of  valvular  injury  lies  in  its  probable  consequence,  namely,  en- 


DISEASE  OF  HEART.  335 

largement  of  the  muscular  walls ;  and  it  makes  all  the  difference 
in  the  world  to  you  and  to  the  patient  to  ascertain  if  this  already 
exists.  Percussion  and  palpation  are  a  much  more  necessary 
part  of  the  examination  than  mere  listening  with  a  stethoscope. 
If  the  heart  is  dilated  or  thickened,  or  dilated  and  thickened, 
your  ascertaining  the  fact  makes  all  the  difference  in  the  world 
to  your  prognosis,  and  to  the  hopes  which  you  have  that  your 
treatment  may  be  successful. 

It  is  obvious  that  in  the  treatment  of  the  disorganized  valves 
themselves,  restorative  medicine  in  the  strictest  sense  must  be 
quite  at  fault.  The  renewal  of  the  destroyed  tissues  is  impos- 
sible, and  equally  so  is  any  compensation  for  the  arrested  func- 
tion. But  indirectly  it  is  almost  as  effective  in  prolonging  life, 
as  if  it  could  put  in  a  new  valve,  or  make  another  muscle  do 
duty  for  the  resting  ventricle.  It  may  repair  those  reparable 
conditions  which  are  so  injurious,  and  which  by  bringing  on  en- 
largement constitute  the  real  danger  in  cardiac  cases.  In  this, 
as  in  all  diseases,  try  and  cure  what  is  curable,  and  trouble  your- 
selves as  little  as  possible  about  bygone  injuries. 

Learn  from  the  histories  you  hear  in  the  wards  what  are  the 
external  causes  which  have  brought  on  the  first  affection  of  the 
health,  and  you  will  thus  learn  the  perils  which  3'our  patient 
with  valvular  injury  has  to  fear.  These  are  placed  roughly  in 
the  order  of  prominence — 

fresh  attacks  of  rheumatism; 

insufficient  food;  ") 

mentiil  anxiety; 

drinking; 

overwork ; 

temporary  violent  exertions. 

Tlie  first  danger  is  to  be  avoided  by  warm  clothing,  dry  air — 
especially  in  the  sleeping  room,  and  a  residence  in  such  a  climate 
as  does  not  naturally  induce  rheumatism.  As  a  rule,  in  the  cli- 
mate of  England,  moderately  high  ground  is  to  be  preferred  to 
low,  and  an  inland  to  a  seaside  or  island  abode.  A  town  life,  as 
being  more  healthily  sedentary  and  avoiding  changes  of  tem- 
perature, is  rather  to  be  chosen  than  rural  occupations. 


>■  producing  anaemia. 


336  DISEASE  OF  HEART. 

DurinfT  the  attacks,  if  unfortunately  thej  come  on,  you  cannot 
do  better  than  adopt  the  full  trea  tment  of  rheumatic  fever,  namely, 
potash  and  opium,  and  especially  blanketing,  as  more  largely  set 
forth  in  my  lecture  on  rheumatic  fever.  And  you  must  leech  or 
cup  the  cardiac  region,  if  there  is  any  pain  there  indicating  the 
probable  presence  of  fresh  endocarditis  or  pericarditis. 

But  do  not  let  the  license  you  give  yourself  of  local  blood- 
letting to  a  moderate  extent  for  the  relief  of  an  acute  condition, 
which  you  fear  may  aggravate  existing  evils, — let  not,  I  say, 
this  license  lead  to  your  adopting  the  old  "heroic"  practice  of 
thinking  to  cure  established  valvular  injuries  by  continuous 
bleeding,  like  our  forefathers  Albertini  and  Valsalva.  They 
fell  into  the  mistake  thus:  they  first  supposed  every  enlarged 
part  was  over-nourished,  or  hypertrophied;  then  they  thought 
that  the  best  thing  to  prevent  its  over-nourishment  was  to  under- 
nourish it;  and  then  finding  that  bleeding  in  moderation  some- 
times lightened  a  few  symptonas,  they  determined  that  it  did  so 
by  under-nourishing  the  heart,  and  that  of  course  the  more  the 
patient  got  of  it  the  better.  Under  the  idea  of  producing  its 
full  influence,  they  bled  frequently  in  small  quantities — the  most 
effectual  way  of  accomplishing  the  end  they  had  in  view,  the  im- 
poverishment of  the  blood.  With  bleeding  for  such  an  end  it 
was  strictly  reasonable  to  join  starvation,  as  certainly  the  most 
direct  way  of  diminishing  nutrition.  What  the  results  would  be 
of  thus  deliberately  inducing  anaemia  we  can  easily  guess,  for 
daily  experience  shows  that  in  none  do  the  hearts  so  rapidly 
become  enlarged,  and  on  none  does  that  enlargement  have  more 
baneful  effects  than  on  those  people  who  are  subjected  to  all  or 
any  of  the  causes  of  anaemia  which  I  have  named.  Had  the 
Sangrado  treatment  really  been  in  vogue  now  in  England,  I 
should  have  certainly  ranked  it  in  the  first  class  of  the  origins 
of  disease  in  patients  with  lesed  valves. 

I  have  spoken  of  the  poor  as  without  doubt  the  most  exposed 
to  the  effects  of  those  agencies  which  produce  or  aggravate  val- 
vular lesion;  but  the  rich  are  by  no  means  exempt,  and  often 
require  the  protection  of  sound  medical  advice.  Even  "insuflS- 
cient  food"  is  not  an  unknown  cause  of  illness  among  them;  the 


DISEASE  OF  HEART.  337 

power  to  buy  it  does  not  always  imply  the  power  to  eat  it.  They 
not  uncommonly  become  anaemic  from  loss  of  vigor  in  the  diges- 
tive organs.  To  counteract  the  risk  of  this  anaemia  I  usually 
recommend  that  persons  with  affected  valves,  should  three  or 
four  times»a  year  take  a  fortnight's  course  of  iron  under  the  eye 
of  their  ordinary  medical  man,  whose  watchfulness  is  needed  to 
prevent  excess.  The  insoluble  forms  of  the  metal,  such  as  the 
sesquioxide,  or  the  finely  pulverized  metallic  iron  made  by  French 
chemists,  or  the  mistura  ferri  composita  are  the  fittest  for  the 
purpose.  Chlorine  also  in  the  form  of  hydrochloric-acid  baths 
is  a  tonic  not  contraindicated  by  any  circumstances  in  this  case, 
and  is  a  good  accompaniment  to  the  iron.  The  habitual  use  of 
a  large  quantity  of  chloride  of  sodium  with  food  is  another  way  of 
guarding  against  anaemia,  which  can  readily  be  adopted  by  the 
patient. 

When  there  is  reason  to  fear  that  dilatation  has  already  begun, 
I  often  join  with  the  iron  small  doses  (from  ^'g-th  to  j'^th  of  a 
grain)  of  strychnine.  If  the  pulse  intermits,  this  remedy  some- 
times exerts  its  tonic  power  over  muscular  fiber  by  restoring 
regularity  of  beat,  and  thus  gives  you  the  satisfaction  of  feeling 
the  good  you  do  with  it.  When  there  is  much  palpitation  on 
occasion  of  slight  nervous  excitement,  especially  if  that  is  joined 
with  irregularity  and  intermittence  of  pulse,  a  few  small  doses 
of  digitalis  are  useful.  Strange  it  is  that  this  vegetable,  which 
makes  a  healthy  heart  first  intermit  and  then  stop  altogether, 
should  bring  back  to  order  the  organ  when  it  is  weak  and  beat- 
ing unevenly !  We  can  only  account  for  the  seeming  anomaly 
by  supposing  it  to  act  as  an  anaesthetic  upon  the  cardiac  nerves, 
withdrawing  them  from  normal  and  needful  stimulation  in  the 
first  case,  and  from  abnormal  and  hurtful  stimulation  in  the 
second.  The  worst  aspect  of  digitalis  is,  tiiat  its  benumbing  in- 
fluence extends  not  to  the  heart  alone,  where  it  is  wanted  in 
proper  cases,  but  to  the  whole  tract  of  the  pneumogastric  nerve; 
it  reduces  the  appetite  and  produces  nausea;  so  I  pray  you  to 
be  cautious,  and  not  to  continue  it  longer  than  necessary. 

While  you  bid  your  patients  live  generously,  you  must  take 
care  to  disabuse  them  of  the  notion  that  the   advice  includes 


338  DISEASE  OF  HEART. 

excess  in  alcohol.  Alcohol  is  really  the  most  ungenerous  diet 
that  there  is.  It  impoverishes  the  blood,  and  there  is  no  surer 
road  to  that  degeneration  of  the  muscular  fiber  which  is  so  much 
to  be  feared.  And  in  heart-disease  it  is  more  especially  hurtful, 
by  quickening  the  -beat,  causing  capillary  congestioi*  and  irre- 
gular circulation,  and  thus  mechanically  inducing  dilatation  of 
the  cavities.  Let  the  alcoholic  drink  be  limited  to  that  qyantity 
which  increases  the  appetite.  In  a  great  many  instances  this 
quantity  may  be  very  shortly  -written  down — 0. 

To  mental  anxieties  perhaps  their  social  relations  expose  the 
rich  quite  as  much  as  the  poor,  and  their  education  makes  them 
more  sensitive.  Both  joys  and  sorrows  affect  them  more  deeply, 
and  instead  of  balancing  one  another  do  equal  harm.  Happiness 
is  as  hurtful  as  misery.  For  example,  I  have  a  patient  whose 
first  attack  of  dilatation  arose  from  grief  at  his  first  wife's  death, 
and  his  second  during  the  honeymoon  of  her  successor.  But 
alas!  ungrateful  discontented  man  seldom  lets  the  blessings  he 
is  daily  receiving  affect  his  emotions  so  deeply  as  his  occasional 
misfortunes,  and  so  ill  luck  is  more  commonly  productive  of 
cardiac  disease  than  good. 

By  overwork  as  a  cause  of  angemia,  I  mean  too  long-continued 
wearying  toil,  either  intellectual  or  bodily.  I  would  have  you 
distinguish  from  it  short  extraordinary  exertions,  to  which  we 
can  sometimes,  though  not  very  commonly,  trace  injury  of  the 
valves,  but  not  direct  degeneration  of  the  heart-walls. 

Now  and  then  a  case  occurs  showing  the  possibility  of  a  valve 
being  ruptured  by  its  own  forced  action.  Thus  I  remember 
seeing  one  of  Tattersall's  stablemen,  under  Dr.  Nairne's  care 
at  St.  George's  Hospital,  who  distinctly  traced  his  first  cardiac 
symptoms  to  a  sudden  pang  which  he  felt  when  running  a  fast 
horse  down  tlie  yard  a  year  before.  After  death  two  of  the 
pouches  of  the  aortic  valve  were  found  torn,  and  from  the  re- 
gurgitation thus  arising  the  ventricles  had  become  enormously 
dilated  during  the  year  that  he  had  lived.  But  the  torn  portions 
were  not  of  normal  structure ;  the  tissue  was  thickened  and 
opaque,  and  therefore  wanting  in  elasticity  or  power  of  resist- 
ance.    And  I  believe  this  always  is  found   to  be  the  case  in 


DISEASE  OF  HEART.  339 

valves  ruptured  by  violent  strains ;  I  am  not  aware  of  any 
instance  of  healthy  valves  having  been  found  broken. 

Where  the  tissue  has  become  bony  and  brittle,  rupture  is 
more  common;  but  then  of  course  it  will  have  been  preceded 
by  a  long  course  of  ill-health,  for  such  an  advanced  lesion  as 
ossification  could  not  exist  without  seriously  incommoding  the 
individual.  You  would  not  be  long  diligent  students  in  the 
dead-house  without  seeing  in  the  dead  body  the  cords  of  a  mitral 
valve  thus  broken,  rather  from  the  quantity  of  lesion  than  from 
any  external  strain  or  violence. 

More  common  still  are  cases  that  you  see  during  life  of  sudden 
pangs  from  exertion — such  as  race-rowing,  jumping,  fighting, — 
sudden  pangs  followed  by  increased  palpitation,  and  other  signs 
of  aggravated  enlargement  of  the  heart.  Yet  the  aggravation 
is  not  such  as  must  surely  accompany  a  broken  valve,  nor  is  the 
path  to  death  so  straight  as  it  was  in  the  case  which  I  have 
related  to  you.  Moreover,  in  some  instances  where  an  autopsy 
reveals  that  the  valves  are  whole,  you  had  previously  heard  a 
history  of  such  pangs,  and  sometimes  had  seen  them  in  the 
wards.  What  is  going  on  in  the  heart  during  these  fits  of 
angina  pectoris  no  one  precisely  knows,  but  it  seems  to  me  very 
probable  that  its  state  is  one  of  temporary  dilatation.  The  pain 
has  the  same  tearing  and  paroxysmal  character  that  you  find 
accompanying  the  distention  of  hollow  fibrous  organs  usually 
insensitive,  such  as  the  stomach,  the  colon,  the  bladder.  The 
pain  is  of  the  same  nature  as  that  felt  in  over-strained  tendons, 
or  muscles  wearied  out  by  sustained  efforts ;  it  appears  associated 
with  the  stretching  of  usually  insensitive  fibers,  and  is  sometimes 
the  most  dreadful  agony  the  body  can  bear,  as  the  inventors  of 
racks  and  other  instruments  of  torture  well  know.  And  the  con- 
sequences too  are  similar,  as  well  as  the  pain  ;  that  is  to  say, 
like  the  bladder  or  the  stomach,  the  heart  may  in  one  case 
completely  recover;  or,  in  a  second,  it  may  be  completely  para- 
lyzed and  cause  death ;  in  a  third,  it  may  remain  partially 
powerless  and  dilated.  As  in  the  bladder,  so  in  the  heart,  any 
one  of  these  results  may  follow. 

Having  said  so  much  about  the  nature  of  injury  by  sudden 


340  DISEASE  OF  HEART. 

strain,  it  is  needless  to  remark  that  it  is  to  be  avoided  bj  all  the 
expedients  that  lie  in  the  patient's  power ;  and  perhaps  the  best 
way  of  strongly  impressing  upon  him  (if  he  is  a  sensible  man) 
the  importance  of  your  advice,  is  to  explain,  that  is  put  into 
plain  words  the  pathology  of  the  case.  I  cannot  agree  with 
those  who  would  make  a  mystery  of  our  science.  I  am  sure  that 
we  are  never  called  upon  to  pervert  the  truth,  seldom  even  to  be 
passively  reticent,  and  that  the  most  thorough  openness  is  always 
the  best  policy.  To  this  end  a  complete  explanation  is  gene- 
rally necessary.  The  patient  must  be  told  how  erroneous  are 
the  vulgar  notions  derived  from  popular  fiction  about  the  extreme 
deadliness  of  organic  disease  ;  the  true  facts  of  the  case  must  be 
stripped  of  their  picturesque  hangings,  and  he  must  be  led  to 
look  upon  his  condition  with  the  same  business-like  reckoning 
of  results  as  a  physician.  Unless  this  is  done,  your  half  truth 
will  act  as  a  lie. 

I  should  strongly  advise  you  to  get  a  habit  of  giving  these 
clinical  lecturettes  in  clear  untechnical  words.  Let  your  patho- 
logy shape  itself  within  your  own  minds  in  such  language  as  all 
educated  people  can  enter  into ;  and  not  only  vfUl  you  be  able 
to  explain  matters  more  easily  to  your  patient,  but  you  will  un- 
derstand them  better  yourself.  For  this  last  statement  "experto 
crede." 

In  practical  lectures  it  is  always  wisest  to  take  chronic  diseases 
ef  the  heart  as  one  individual  subject,  for  this  is  the  way  in 
which  you  have  to  think  of  them  at  the  bedside.  You  should 
not  treat  patients  with  spoilt  valves  on  one  principle,  those  with 
dilated  ventricles  on  another,  those  with  thickened  ventricles  on 
a  third ;  but,  as  I  have  tried  to  make  you  think,  each  and  all 
with  a  reference  to  the  same  function  impeded  in  the  same 
manner.  Division  leads  to  unnecessary  repetition,  and  you  may 
observe  that  I  am  careful  to  avoid  it  both  in  the  way  in  which  I 
class  the  patients  in  the  wards  for  instruction,  and  in  the  ex- 
tracts I  make  from  case-books  for  the  lecture-room.  I  do  this 
with  a  design  of  impressing  upon  you  what  I  consider  the  main 
points  in  the  management  of  diseased  hearts,  viz. — 

1.  The  importance  of  valvular  lesions  consists  in  their  liability 
to  cause  enlargement  of  the  heart. 


DISEASE  OF  HEART.  341 

2.  In  auscultation  we  should  strive  more  to  find  out  the  state 
of  the  heart-walls  than  of  the  valves. 

3.  The  danger  of  enlargement  is  greatest  where  the  muscular 
fiber  is  weakest. 

4.  The  muscular  fiber  is  weakest  where  the  blood  is  most 
anaemic. 

5.  The  principal  object,  therefore,  of  treatment  is  to  avoid 
anaemia. 


{Clinical,  St.  Mary's,  January  30,  1863.) 

Eliza  M.,  an  unmarried  woman,  aged  twenty-six,  has  been  in 
the  hospital  four  times  during  the  last  three  years  with  attacks 
of  haemoptysis  and  dyspnoea,  arising  from  valvular  disease  of  the 
heart.  She  was  last  admitted  January  16,  with  dyspnoea  ac- 
companied by  excessive  lividness  of  the  face.  She  was  soon 
relieved  by  the  recumbent  posture  and  half  a  dozen  leeches  to 
the  cardiac  region.  My  reason  for  mentioning  the  case  to-day 
is  to  draw  your  attention  to  the  dyspeptic  symptoms  which  seem 
dependent  upon  the  disease  of  the  heart.  On  admission  she 
said  that  she  vomited  up  all  her  food,  and  although  she  only  did 
that  once  after  coming  into  the  hospital,  still  she  suffered  from 
constant  nausea  after  eating,  and  tympanitic  distension  of  the 
intestines.  I  have  often  found  this  form  of  indigestion  in  cases 
of  heart  affection.  There  is  nausea,  vomiting,  sometimes  a  great 
collection  of  mucus  in  the  stomach,  and  intestinal  flatulence.  I 
attribute  the  nausea  and  vomiting  partly  to  the  constant  jar 
communicated  to  the  walls  of  the  stomach  by  the  palpitating 
heart,  and  which  acts  somewhat  as  the  rocking  of  a  ship  pro- 
duces sea-sickness.  Partly  also  I  think  it  may  be  due  to  the 
general  venous  congestion  which  I  have  no  doubt  exists  equally 
in  the  mucous  membrane  and  in  the  external  skin.  The  flatus 
in  the  digestive  canal  I  think  arises  from  the  deficiency  of  ab- 
sorption, produced  by  congestion  of  the  portal  system. 

You  must  not  look  upon  wind  as  a  purely  abnormal  denizen 
of  the  alimentary  canal.     It  would   be   a  very  abnormal   state 


342  DISEASE  OF  HEART. 

of  things  indeed  if  there  were  none  found  there.  The  greater 
part  of  it  is  carbonic  acid  and  atmospheric  air,  derived  from  and 
swallowed  with  the  food.  But  in  health  its  quantity  is  limited 
and  kept  from  inconvenient  excess  bj  its  continuous  passage  by 
endosmosis  into  the  portal  and  venous  blood.  Now  it  is  a  familiar 
law  of  osmosis  that  the  ratio  of  the  rapidity  of  its  current  bears 
a  direct  relation  to  the  motion  of  the  fluid  towards  which  it  sets. 
Obviously,  then,  obstructions  to  the  circulation,  by  diminishing 
the  quickness  of  the  moving  blood,  must  impede  absorption,  and 
so  allow  the  flatus  to  accumulate.  It  must  be  viewed  as  a  col- 
lection not  as  an  eff"usion. 

As  regards  remedies  for  this  flatulent  dyspepsia  of  cardiac 
patients,  I  have  found  hydrocyanic  acid  have  a  beneficial  eff'ect. 
And  in  this  case  especially  to  give  it  is  to  accomplish  two 
indicata  with  the  same  agent ;  for  by  its  general  astion  upon 
the  pneumogastric  nerve  it  alleviates  the  dyspnoea,  at  the  same 
time  that  it  deadens  the  over  sensibility  of  the  gastric  plexus  in 
special. 


LECTURE    XXVI. 

PURPURA. 

Descriptive  defiriition  of  purpura — Case  1.  Young  man  affected 
with  fatal  hemorrhage  and  purpura  without  previous  disease 
— Case  2.  Menorrhagia  and  purp)ura  in  a  girl  othertvise 
healthy — Case  3.  Purpura  in  a  fatal  case  of  diseased  heart 
and  kidneys — Pathology  of  purpura — Its  connection  ivith 
lesions  of  the  circulating  system — Its  treatment  based  on  its 
pathology — Caiitions  respecting  the  administration  of  digitalis. 
— Case  4.  Purpura  fatal  by  hemorrhage  into  the  brain. 

{Clinical,  St.  Mary's,  February  6,  1864.) 

I  WISH  to  call  your  attention  to-day  to  three  examples  of  pur- 
pura under  my  care  this  week,  which  illustrate  the  phenomenon 
under  several  different  aspects. 

Purpura,  or  "the  purples,"  consists  of  a  diseased  state  of  the 
capillaries,  which  causes  them  to  rupture  idiopathically  or  of 
their  own  accord,  just  as  they  would  do  in  consequence  of  local 
violence.  On  soft  or  loosely  constructed  surfaces,  such  as 
mucous  membranes,  the  escaped  blood  flows  away  in  a  fluid 
state ;  where  a  tougher  structure  prevents  this  escape,  us  in  the 
external  skin  for  example,  it  forms  purplish  black  spots  of 
rounded  shape  and  various  sizes;  in  parenchymatous  or  semi- 
parenchymatous  tissues,  such  as  the  brain  or  lungs,  it  may  col- 
lect into  masses  which  lacerate  their  substance  and  obstruct  their 
functions. 

Case  1.  John  K.,  a  laborer,  aged  thirty-five,  previously  quite 
well,  was  taken  ill  at  tea-time  on  January  29,  with  bleeding 
from  the  mouth.  This  hemorrhage  rapidly  increased,  and  be- 
came very  profuse ;   so  that  by  the  evening  of  the  1st  instant. 


344  PURPURA. 

wlicn  he  came  up  by  railway  to  St.  Mary's,  he  reckons  that  he 
lost  a  gallon.  And  indeed  it  was  very  copious,  for  on  each  of 
the  first  two  days  of  his  being  here  there  was  very  nearly  a  pint 
of  fluid,  exactly  like  pure  blood,  with  a  vermilion  froth  on  the 
top,  in  the  porringers  by  his  bedside.  But  a  good  deal  of  saliva 
■was  mixed  with  it,  so  much  at  least  as  to  prevent  its  coagulation, 
except  in  very  small  broken  clots.  On  admission  his  mouth  was 
full  of  clotted  blood,  which  adhered  to  the  gums ;  on  the  tongue 
w^ere  half  a  dozen  black  vesicles  of  the  size  and  shape  of  split 
peas,  and  blood  was  oozing  from  their  edges.  On  the  lips  and 
face,  on  the  hands,  arms,  and  various  other  parts  of  the  front  of 
the  body,  were  numerous  black  spots  of  about  the  same  diameter 
as  those  on  the  tongue,  but  not  raised  above  the  surface.  His 
urine  contained  blood  and,  of  course,  albumen;  but  I  could  not 
find  that  blood  had  been  passed  from  the  bowels.  He  said  he 
felt  weak  and  tremulous;  but  he  had  walked  to  the  hospital, 
and  he  sat  upright,  waiting  for  a  bed  to  be  prepared  for  him, 
for  some  time  without  faintness.  There  was  color  also  in  his 
cheeks  and  lips,  and  altogether  much  less  exhaustion  than  one 
would  have  looked  for  after  such  severe  hemorrhage.  His  ap- 
petite was  not  afi"ected,  and  the  bowels  were  opened  naturally 
"without  medicine. 

He  was  ordered  ice,  sulphuric  acid  and  turpentine  draughts, 
and  "tea-cup  diet"  of  milk  and  beef-tea,  with  a  wash  of  log- 
wood, catechu,  and  sulphuric  acid,  for  the  mouth. 

On  the  3d  there  was  little  if  any  improvement  in  the  local 
symptom,  but  his  color  and  pulse  had  not  failed.  He  was  bid- 
den, in  addition  to  the  previous  treatment,  to  keep  in  his  mouth 
a  lump  of  ice  smeared  M'ith  powdered  tannin. 

On  the  4th  the  hemorrhage  from  the  mouth  was  not  lessened 
much;  there  was  about  three-quarters  of  a  pint  of  froth-covered 
blood.  It  was  stained  brown  by  the  local  applications — in  fact 
tanned.  The  pulse  was  quicker  and  weaker,  about  108  in  the 
minute  and  uneven.  An  ounce  and  a  half  of  infusion  of  digi- 
talis was  ordered  to  be  taken  every  third  hour,  and  the  sulphuric 
acid  and  turpentine  were  left  ofi". 

On  the  5th  (yesterday)  the  pulse  was  120  in  the  morning, 


PURPURA.  345 

110  in  the  afternoon,  regular,  even,  and  narrower  than  on  the 
previous  afternoon.  The  hemorrhage  •was  not  diminished.  Sore 
throat,  faintness,  and  nausea  were  complained  of.  After  he  had 
taken  six  doses  the  digitalis  draughts  were  given  every  four  hours 
only. 

Late  last  night  the  breathing  became  short  and  difficult,  and 
he  died  early  this  morning.  Our  secretary  telegraphed  to  the 
poor  man's  wife  at  the  village  where  they  lived.  The  telegraph- 
clerk  was  unable  at  first  to  deliver  the  message,  there  being 
several  people  of  the  same  name  in  the  place;  but  hearing  that 
a  few  days  before  a  man  bleeding  much  from  the  mouth  had 
gone  by  train  to  London,  he  tracked  him  backwards  from  the 
station  to  his  cottage  by  the  blood  which  had  been  spat  upon 
walls  and  stones  by  the  way-side.  This  shows  that  the  account  of 
the  excessive  hemorrhage  before  admission  was  not  exaggerated. 

[A  post-mortem  examination  was  made  on  the  8th,  two  daj's  and  a  half  after 
death.  The  whole  front  of  the  body  was  covered  with  spots  of  purpura,  of  which 
those  on  the  chest  had  pale-yellow  centers.  The  rest  of  the  skin  was  very  pale 
and  there  were  very  few  spots  on  the  back.  There  were  numerous  spots  of  pur- 
pura on  the  pleura,  pericardium,  small  intestines,  bladder,  bronchi,  trachea,  and 
larynx.  In  the  upper  part  of  the  latter  organ  they  became  more  numerous,  and 
in  the  fauces  and  tongue  formed  a  continuous  discoloration.  On  the  tongue 
they  were  black  and  swollen  as  before  death,  and  from  the  pillars  of  the  fauces 
blood  oozed  on  their  being  handled.  There  was  no  purpura  on  the  oesophagus. 
The  left  auricle  contained  a  firm  non-adherent  clot  of  fibrin,  and  there  was  an- 
other similar  clot  loose  in  the  aorta.  The  heart  was  hard  and  firmly  contracted. 
The  ventricles  are  preserved  unopened.  The  other  viscera  were  quite  normal  in 
appearance.] 

Case  2.  Jane  N.,  aged  nineteen,  spinster,  came  in  on  January 
29.  She  has  a  transparent  ivory  complexion,  firm  large  limbs 
and  muscles,  and  an  aspect  of  strength.  She  has  always  enjoyed 
good  health,  but  during  the  last  three  months  the  catamenia  have 
been  very  profuse,  and  have  gone  on  lasting  longer  and  longer 
each  period,  till  now  she  has  hardly  a  week's  interval.  During 
the  week  before  admission  she  several  times  found  blood  in  her 
m.outh,  and  on  the  26th  purple  spots  came  out  on  the  face,  arms, 
bosom,  and  legs,  and  continued  to  increase  in  numbers  daily. 
They  were  of  sundry  sizes,  from  that  of  a  mustard  seed  up  to 
that  of  a  pea,  the  smaller  being  far  the  most  numerous.     They 


346  PURPURA. 

were  of  an  intense  purple  color,  and  presented  a  singular  appear- 
ance from  their  striking  contrast  with  her  clear  waxy  complexion, 
the  hue  being  perfectly'  complimentary.  Their  surface  was  not 
raised  above  the  neighboring  skin.  I  saw  none  on  the  mucous 
membranes  of  the  mouth,  but  her  gums  looked  a  little  red  at  the 
edges. 

Her  bowels  were  regular.  The  urine  could  not  be  examined 
on  account  of  the  presence  of  the  catamenia.  She  had  lust  her 
appetite,  but  I  think  that  was  accounted  for  by  her  sorrow  at 
parting  Avith  her  mother  and  coming  into  a  hospital,  as  she  has 
eaten  fairly  since  she  has  found  it  to  be  not  such  a  terrible  place 
as  she  fancied. 

She  was  ordered  the  following: — 

^i  Dilute  sulphuric  acid,  min.  xxx, 
Tincture  of  digitalis,  min.  xv. 
Camphor  water,  fl.  oz.  j, 

every  4  hours. 
A  tea-cup  of  milk  or  beef -tea  every  2  hours. 

On  the  morrow  I  found  her  appetite  was  not  so  entirely  lost 
as  she  said;  so  I  ordered  her  broth  and  meat,  potatoes  and  a 
lemon,  and  on  February  3  ordinary  meat  diet. 

Twenty-four  hours  after  commencing  the  draughts  I  pointed 
out  to  you  that  the  center  of  each  spot  was  lighter  than  the  cir- 
cumference. It  became  distinctly  yellow  to  the  naked  eye,  and 
the  dark  color  gradually  faded  away  altogether  by  February  4. 
The  sanguineous  discharge  ceased  at  the  same  time.  She  is 
quite  convalescent,  but  I  observed  that  after  an  interview  with 
her  mother  yesterday  she  was  paler  in  the  lips  and  depressed  in 
spirits;  so  I  shall  keep  her  in  a  little  bit  to  watch  against  a  re- 
lapse and  give  iier  a  good  rest. 

Case  3.  William  11,,  a  butler,  aged  forty-five,  was  admitted 
on  January  29  sinking  with  emaciation,  anaemia,  and  pain  in  the 
cardiac  region.  The  anatomical  lesions  found  at  the  post-mortem 
examination  on  February  3  were  a  dilated  heart,  with  its  mitral 
valve  degenerated  into  wart-like  growths,  and  kidneys  atrophied 


PURPURA.  347 

through  the  occupation  of  their  substance  by  many  curiously 
large  cysts. 

The  imperfection  of  the  mitral  valve  had  been  known  before 
death,  but  that  did  not  explain  the  disease;  and  the  circum- 
stances prevented  any  further  diagnosis,  or  much  association  of 
the  symptoms  during  life  with  the  appearances  on  dissection. 

The  chief  causes  of  death  do  not  therefore  offer  a  profitable 
opportunity  of  clinical  instruction,  and  I  cite  the  case  to-day  to 
notice  a  secondary  phenomenon.  Two  days  before  death  there 
appeared  a  large  blotch  of  purpura  on  the  nose,  occupying  the 
greater  part  of  the  feature,  and  another  spot  on  the  left  hand, 
which  was  slightly  oedematous.  The  discoloration  remained  in 
the  dead  body.     The  blood  was  fluid. 

These  three  cases  present  to  you  three  aspects  of  purpura. 

In  the  first  two  the  disease  was  due  to  a  marked  loss  of  func- 
tion in  the  capillary  vessels,  so  that  their  coats  v,-ere  ruptured, 
and  the  contained  fluid  oozed  out.  In  the  fii-st  danger  arose 
from  the  accidental  location  of  this  oozing  in  a  loose  surface,  so 
that  tlie  hemorrhage  was  excessive.  In  the  second  there  was 
no  danger  at  all.  In  the  third  the  deficiency  of  the  capillaries 
was  at  a  minimum,  and  would  not  alone  have  given  rise  to  ex- 
travasation; but  it  was  supplemented  by  the  impediment  to  the 
circulation  in  the  heart,  and  probably  by  the  retention  of  urea 
in  the  blood.     It  was  in  itself  unimportant. 

Like  all  diseases  of  the  peripheral  circulating  system,  pur- 
pura is  most  common  in  the  parts  most  distant  from  the  center. 
Such  is  the  rule,  though  its  want  of  universality  is  exemplified 
by  the  instances  before  us.  But  it  is  not  most  common  in  the 
most  dependent  parts,  and  in  the  legs  it  appears  as  often  on  the 
front  as  the  back,  on  the  body  almost  always  on  the  front.  This 
seems  to  remove  its  etiology  from  the  category  of  being  primarily 
traceable  to  lesion  of  the  central  organ  of  circulation  or  of  the 
mass  of  the  circulated  fluid.  Were  such  its  origin,  it  would 
appear  in  cases  where  the  first  is  most  afi"ected,  and  in  places 
where  the  latter  is  most  abundant  and  most  unhealthy. 

You  must  not  fall  into  the  old-fashioned  error,  inculcated  when 


348  PURPURA. 

I  was  a  pupil,  of  lazily  attributing  all  illnesses  where  the  blood 
is  abnormal  in  composition  to  "diseases  of  the  blood,"  and  there 
ending  it.  The  blood  is  like  a  pond  or  reservoir  attached  to  some 
great  manufactories:  the  refuse  of  the  manufacture  flows  into  it, 
and  the  engine  boilers  are  fed  from  it;  waste  products  and  latent 
power  are  mingled  in  its  streams.  If  there  is  anything  unusually 
foul  in  the  water,  the  master  does  not  lay  the  blame  of  that  foul- 
ness on  the  innocent  element,  but  traces  it  to  defects  in  the  pro- 
cesses drained  and  fed.  So  in  purpura,  the  circulating  fluid  is 
probably  always  abnormal ;  but  it  is  surely  unwise  to  stop  our 
explanation  at  this  point,  and  to  search  no  further.  For  the 
hemorrhage,  whether  free  or  into  the  cutis,  makes  it  abnormal, 
and  the  degeneration  of  the  red  disks,  discernible  by  the  micro- 
scope, is  just  what  is  found  in  cases  where  there  is  no  purpura. 
It  is  surely  going  backwards,  when  the  function  we  see  to  be 
deficient  (namely,  the  retention  of  the  blood)  is  a  function  of  the 
capillary  vessels,  to  say  that  their  diseased  contents  are  a  cause 
of  that  deficiency. 

On  this  pathology  is  based  the  treatment.  The  less  severe 
cases  will  recover  under  the  use  of  cool  unirritating,  but  nutri- 
tious, diet  with  vegetable  and  mineral  acids,  which  astringe  the 
capillaries.  I  think  very  possibly  the  young  woman  Jane  N. 
would  have  done  so;  though  not  so  quickly  as  she  has  now  re- 
covered, because  mineral  acids  alone  are  slow  to  stop  menor- 
rhagia,  Avith  which,  as  well  as  with  purpura,  you  will  remember 
her  to  have  been  affected.  But  you  saw  that  this  treatment  had 
no  influence  over  the  dangerous  purpura  of  the  first  patient, 
although  supplemented  by  other  very  powerful  astringents.  The 
most  powerful  remedy  taken  in  both  instances  has  been  digitalis, 
whose  agency  in  diminishing  the  area  of  the  circulating  system 
(probably  through  the  functions  of  the  involuntary  nerves)  I 
have  often  pointed  out  to  you.  Under  its  use  the  artery  becomes 
smaller,  the  pulse-wave  is  narrowed  and  hemorrhage  ceases, 
equally  when  it  is  on  the  loose  surface  of  a  mucous  membrane, 
as  when  it  is  subcutaneous. 

You  saw  the  purple  blotches  on  the  young  woman  fade  away 
at  a  marvellously  quick  rate ;  and  you  saw  them  fade  away  from 


PURPURA.  349 

the  center,  not  from  the  circumference,  exhibiting  yellow  spots 
in  the  middle  while  the  rim  was  still  dark,  thus  proving  that  the 
action  is  not  merely  peripheral,  but  internal.  At  the  same  time 
you  heard  that  the  vaginal  hemorrhage  was  also  ceasing,  as  it 
usually  does  in  simple  menorrhagia  under  the  action  of  digitalis. 
In  the  first  related  case  there  is  no  evidence  of  curative  action, 
except  the  yellow  centers  to  some  of  the  blotches  seen  in  the 
dead  body.  In  the  third  case  the  purpura  was  such  an  unimport- 
ant part  of  the  patient's  illness,  that  it  had  no  treatment  at  all. 

The  chief  caution  which  I  think  it  necessary  to  give  you  about 
the  administration  of  this  remedy,  is  that  you  should  provide 
against  the  danger  accruing  from  the  sudden  uprising  of  the 
patient.  From  the  diminution  of  the  area  of  the  vessels  so  much 
less  blood  is  sent  up  into  the  brain,  that  fatal  fainting  may  ensue 
if  the  usual  hasty  demand  entailed  by  this  change  of  posture  is 
made.  The  symptoms  of  deleterious  action,  and  which  warn 
us  to  suspend  the  employment  of  digitalis,  are  giddiness  and 
nausea,  accompanied  sometimes  by  irregularity  of  pulse.  Dilata- 
tion of  the  pupils,  cold  sweats,  and  complete  syncope,  alluded 
to  in  your  books  of  materia  medica,  are  later  phenomena,  which 
I  have  not  had  an  opportunity  of  witnessing,  and  before  the 
supervention  of  which  you  ought  to  have  left  off  your  treatment. 

Digitalis  seldom,  if  ever,  begins  to  do  harm  till  it  has  ceased 
to  do  good,  and  till  therefore  the  necessity  for  it  has  passed. 
When  the  condition  for  which  it  may  be  wisely  prescribed  has 
passed  away,  then,  and  rarely  before  then,  its  poisonous  power 
is  exerted.  And  the  more  and  more  the  original  morbid  con- 
dition is  departed  from,  so  is  the  novel  morbid  condition,  the 
poisoning  by  the  vegetable,  developed.  Hence  its  action  appears 
to  increase.  Metaphorically  it  may  be  called  "  cumulative  ;"  but 
the  use  of  that  word  must  not  lead  you  to  suppose  that  soluble 
alkaloids,  such  as  those  in  foxglove,  are  likely  to  accumulate  in 
substance  in  the  blood.  The  stricter  explanation  would  be  that 
its  action  is  permanent,  and  therefore  that  each  new  dose  adds 
to  it. 

This  account  of  the  action  of  digitalis  affords  a  reason  for  the 
23 


350  PURPURA. 

plan,  which  you  see  me  adopt,  of  diminishing  forthwith  the  dose, 
directly  that  a  beneficial  effect  has  begun  to  be  produced. 


[Clinical^  St.  Marys^  February  25,  1864.) 

Having  so  very  lately  lectured  on  the  subject  of  purpura,  I 
shall  bring  before  you,  as  an  appendix  to  that  lecture,  another 
case;  though,  as  a  fatal  one  and  not  seen  by  you  or  me  during 
life,  it  is  but  little  instructive  taken  singly. 

Two  days  ago  a  man,  apparently  of  about  thirty,  was  brought 
in  evidently  moribund,  who  was  stated  to  have  had  "typhus 
fever."  He  died  an  hour  and  a  half  afterwards,  without  having 
manifested  any  diagnostic  symptoms.  At  the  post-mortem  ex- 
amination yesterday  we  observed  on  the  dorsum  of  one  foot  a 
small  spot  of  purpura,  another  at  the  side  of  the  leg,  and  a  good 
many  more  on  the  back.  The  largest  were  about  one-eighth  of 
an  inch  in  diameter.  The  skin  in  many  parts  of  the  person  was 
mottled,  like  that  of  a  corpse  when  decomposition  is  commencing, 
the  face  was  purple,  and  the  scrotum  was  reddish  purple  as  if 
bruised.  The  body  was  well  proportioned,  and  there  was  a 
healthy  quantity  of  firm  adipose  tissue  in  the  walls  of  the  belly. 
The  heart  was  hard  and  large,  weighing  with  the  pericardium 
one  pound  ten  ounces.  The  pericardium  was  universally  adherent, 
as  if  from  long  past  inflammation,  no  connecting  fibrin  being 
visible.  The  valves  were  healthy,  and  in  the  cavities  were  con- 
tained the  usual  fibrinous  coagula;  there  was  none  in  the  arteries 
or  veins.  No  trace  of  chronic  organic  lesion  was  detected  in 
any  other  organ. 

I  show  you  here  specimens  removed  from  several  of  the  viscera, 
which  present  a  singular  and  uniform  appearance,  the  differences 
being  assignable  generally  to  their  different  anatomical  struc- 
ture. Here  are  pieces  of  the  brain,  of  the  liver,  and  of  the  small 
intestines,  the  kidneys,  and  the  heart.  You  see  scattered  over 
them,  inside  and  out,  dark  spots  of  purpura,  such  as  I  have 
described  on  the  skin.  This  gives  a  very  strange  aspect  to  the 
kidneys,  which  look  like  the  speckled  belly  of  a  trout.    In  a  few 


PURPURA.  351 

of  the  spots  the  fibrin  seems  to  have  separated  itself,  forming  a 
vellow  center  to  the  effused  blood.  There  is  no  halo  of  inflam- 
mation around  any  of  them.  Many  of  the  spots  in  the  liver  are 
more  yellow  than  red. 

In  the  brain  the  spots  are  large,  and  branch  out  along  the 
course  of  the  vessels  on  the  surface.  In  the  right  anterior  lobe 
the  nervous  substance  is  broken  up  by  a  large  black  gelatinous 
clot  of  blood.  It  is  evidently,  as  you  may  feel,  of  considerable 
size,  at  least  twice  as  big  as  a  chestnut,  but  I  wish  to  harden  it 
in  spirit  before  I  make  a  section.  There  are  two  more  clots 
about  the  size  of  small  peas  at  the  back  part  of  the  hemispheres. 
No  other  abnormal  appearances  were  observed,  and  this  clot 
in  the  brain  is  enough  to  account  for  death. 

The  history  of  the  case,  which  I  have  since  obtained,  is  as 
follows: — The  patient  had  previously  suffered  twice  from  acute 
rheumatism,  and  since  November  last  had  been  badly  off,  living 
principally  upon  potatoes  and  bacon,  but  was  in  his  usual  health 
and  spirits  on  the  18th  instant.  In  the  evening  of  that  day  he 
was  attacked  with  sickness,  pains  in  the  joints,  pains  in  the  side, 
thirst  and  feverishness,  which  symptoms  went  on  from  bad  to 
worse.  On  the  21st  he  was  seen  by  Dr.  Asprey,  the  resident 
medical  officer  at  the  Western  General  Dispensary,  and  found 
to  have  excessive  pain  in  the  joints  and  a  brown  tongue.  In 
the  evening  he  became  delirious.  On  the  22d  Dr.  Asprey  found 
him  in  a  state  of  partial  coma,  but  capable  of  being  roused  by 
effort,  and  certainly  not  anywhere  paralytic.  The  tongue  was 
dry  and  brown,  and  the  pupils  dilated.  On  the  same  evening 
he  was  brought  to  the  hospital,  as  I  have  related,  just  before  he 
breathed  his  last. 

This  case  shows  how  serious  may  be  the  consequences  of 
purpura,  a  condition  which,  judging  from  the  more  ordinary 
examples  seen  by  us,  we  are  in  the  habit  of  rating  low  down  in 
the  scale  of  causes  of  mortality. 

In  a  case  of  cerebral  hemorrhage  like  this  paralysis  and 
apoplexy  were  not  to  be  expected,  because  the  central  parts  of 
the  brain  were  not  pressed  upon,  the  sanguinecus  effusions  taking 
their  orifrin  from  and  beinor  confined  to  the  surface.     I  remem- 


352  PURPURA. 

ber  the  case  of  a  young  woman  who,  after  a  mental  affliction, 
died  with  typh-like  symptoms  not  very  dissimilar  to  this  man's. 
There  was  found  in  the  brain  a  clot  of  blood  so  large  as  to  con- 
ceal the  greater  part  of  one  hemisphere,  but  it  was  thin  and  lay 
quite  on  the  surface ;  so  that  I  suppose  it  did  not  compress  the 
inner  portions  of  the  cerebral  substance ;  for  there  had  been  no 
paralysis.  It  is  not  so  much  the  size,  as  the  shape,  and  still 
more  the  situation  of  clots  which  make  them  apoplectic  or  not. 
A  clot,  one-tenth  of  the  size  of  this,  in  the  fornix  or  hippocampi 
would  certainly  have  been  apoplectic. 


LECTURE   XXVII. 
ANEMIA. 

Part  1. — History  of  a  case  of  ansemia — Objections  to  the  nomen- 
clature of  the  disease — Its  pathology — It  consists  of  a  func- 
tional deficiency  of  life  in  the  blood-making  organs — Applica- 
tion to  this  case — The  defective  morbid  anatomy  does  not  im- 
pede our  treatment — Transitory  curable  states  usually  depend- 
ent on  the  mucous  membranes,  which  have  little  post-mortal 
anatomy — Sketch  of  the  active  life  of  mucous  membranes — 
Their  importance  in  disease — Effect  on  health  of  their  dimin- 
ished vitality — Application  of  this  pathology  to  practice — In- 
tention of  treatment  to  introduce  nitrogenous  food,  iro7i,  and 
chlorine — Mode  of  doing  this,  its  effects,  and  reflections 
thereon. 

Part  II. — Effect  of  ansemia  on  the  mental  faculties — Practical 
deductions. 

Part  III. — Ansemia,  when  the  result  of  permanent  organic  lesion, 
amenable  to  the  same  treatment  as  when  functional. 

(Part  I. — Clinical,  St.  Mary's,  November  5,  1861.) 

I  AM  about  to  make  a  common  and  typical  case  of  ansemia 
the  text  on  which  to  hang  a  few  practical  observations  on  that 
disease. 

You  will  all  remember  the  corpse-like  paleness,  made  the 
more  striking  by  red  hair,  of  a  girl  we  first  visited  this  day 
fortnight,  named  Margaret  C.  She  smiled  courteously,  though 
quite  unable  to  raise  herself  from  the  bed,  and  in  answer  to 
cross-examination  gave  her  history  as  follows : 

Her  age  is  twenty,  and  she  seems  to  have  enjoyed  generally 
very  good  health,  as  is* shown  by  her  remembering  that  she  had 


354  ANAEMIA. 

such  an  unimportant  discomfort  as  a  pain  in  the  right  side  when 
she  was  a  school-girl  of  seven.  She  was  carefully  brought  up  by 
a  step-father  in  a  higher  class  of  life  ;  but  three  years  ago  she 
lost  him,  and  had  to  go  into  service  as  a  housemaid  at  the  age  of 
seventeen.  For  that  work  she  was  scarcely  strong  enough,  and 
had  been  too  tenderly  nurtured  ;  so  after  eighteen  months'  trial 
she  gave  it  up,  and  was  apprenticed  to  a  Berlin-wool  shop.  There 
her  mental  superiority  was  recognized,  for  she  quickly  became 
forewoman,  with  three  girls  under  her,  in  a  shop  at  Maidstone. 
She  felt  the  responsibility  a  good  deal,  and  also  thought  the 
closeness  of  the  shop  did  not  suit  her,  although  it  did  not  make 
the  others  ill.  However  she  retained  in  her  face  a  high  color, 
for  which  she  seems  to  be  somewhat  admired,  till  nine  months 
ago,  when  she  began  to  lose  it,  and  in  a  few  weeks  became  as 
wax-like  in  hue  as  she  is  now.  In  the  first  stage  of  her  ailing 
the  appetite  Avas  large,  so  that  she  always  felt  in  want  of  food ; 
but  after  three  months  it  failed,  then  ceased  entirely,  and  she 
took  a  disgust  to  all  nutritious  articles  of  diet.  She  had  a  good 
deal  of  pain  in  the  epigastrium,  and  to  the  left  side  of  it,  and 
also  suffered  from  palpitations  and  pain  at  the  heart.  A  quarter 
of  a  year  ago  she  spat  up  some  blood,  and  had  a  little  cough, 
which  frightened  her  much.  Thrice  durino;  the  nine  months  she 
has  had  attacks  of  low  spirits,  with  crying,  which  is  usually  set 
down  to  hysterics ;  yet  there  is  nothing  abnormal  in  a  girl  being 
sad  when  she  is  out  of  health,  or  in  her  crying  when  she  is  sad, 
and  Margaret  C.  does  not  appear  at  all  hysterical  now.  The 
catamenia  had  always  been  quite  regular  and  sufficient  till  the 
commencement  of  the  angemia  nine  months  ago,  when  they  began 
to  get  scantier  and  scantier,  and  at  last  ceased  entirely.  The 
urine  is  pale  and  watery,  the  stools  are  scanty  and  steadily  rare ; 
but  there  is  never  any  sudden  gush  of  bulky  motions,  no  diar- 
rhoea alternating  with  constipation,  or  other  indications  of  accu- 
mulation of  fiBces  in  the  intestines. 

The  patient  expands  her  chest  perfectly,  and  there  are  no 
signs  in  the  lungs  to  give  rise  to  a  suspicion  of  tubercle,  or  at 
all  events  of  tubercle  in  such  a  quantity  as  to  account  for  the 
antBraia.     Tliere  was  at  first  a  soft  systolic  murmur  in  the  heart 


ANEMIA.  355 

when  she  was  agitated,  which  went  away  after  she  had  rested  in 
bed  five  days. 

First,  for  the  name  by  which  I  have  ah-eady  designated  this 
girl's  disease.  Anoeraia,  or  "  bloodlessness,"  means  in  scientific 
language  a  want  of  red  disks  in  the  blood.  The  word  has  been 
objected  to,  because  it  has  been  supposed  to  imply  etymologically 
that  there  is  a  deficiency  in  tlie  actual  quantity  of  circulating 
fluid,  of  which  deficiency  in  quantity  there  is  truly  no  proof. 
And  "spangemia,"  or  "thinness  of  blood,"  has  been  proposed 
in  its  stead.  Such  accuracy  would  be  highly  praisewortiiy,  if  it 
were  only  accurate ;  but  really  the  mere  fact  of  thinness  does 
not  hit  the  essential  feature  of  the  disease  ;  for  the  specific 
gravity  of  the  blood  might  be  raised  as  high  as  you  like,  but  if 
you  did  not  restore  the  red  blood-disks  nothing  would  be  gained; 
the  morbid  state  would  still  exist.  In  truth  there  is  no  occasion 
for  fault-finding.  "  Anseraia,"  by  the  analogy  of  Greek  etymo- 
logy, does  not  mean  deficient  quantity  of  blood,  but  deficient 
quality,  just  as  in  Aristophanes  aTzpoaijno^  does  not  mean  a  man 
"without  a  face,"  but  "with  an  ugly  face,"  avapidnog  means  "dif- 
ficult to  count,"  and  so  on  in  numerous  instances  of  the  use  of 
the  a  privative.  I  shall  therefore  contentedly  use  the  term 
anaemia  to  include  all  cases  in  which  the  amount  of  blood- disks 
is  below  the  normal  proportion. 

Anaemia  has  existed  during  life  in  a  great  number  of  the 
patients  from  whose  bodies  has  been  taken  the  organically 
changed  tissues  which  you  see  preserved  in  museums  and  shown 
in  lectures  on  morbid  anatomy,  and  which  may  also  be  found  out 
by  diagnosis.  In  other  cases  of  equal  import  and  prominence, 
anaemia  is  wanting.  Again,  very  frequently  you  find  it  in  a 
high  degree  in  cases  where  there  can  be  discovered  no  organic 
changes  of  the  solids  at  all,  and  where,  from  the  transitory  nature 
of  the  bloodlessness,  there  is  reason  to  conclude  that  such  organic 
changes  do  not  exist.  Under  this  last  category  comes  the  patient 
who  is  the  occasion  of  to-day's  lecture. 

To  understand  how  it  is  that  so  many  causes  are  followed  by 
the  same  effect,  and  by  an  effect  not  at  all  proportioned  to  the 
general  importance  or  want  of  importance  of  the  cause,  you  must 


356  AN/EMIA. 

reflect  upon  the  true  relation  which  the  blood  bears  to  the  rest 
of  the  organism.  It  may  be  compared  to  a  chief  thoroughfare 
in  a  great  city.  Very  few  trades,  still  fewer  manufactures,  are 
carried  on  out  of  doors  or  in  the  street  it?elf,  yet  from  the  nature, 
the  number,  the  pace,  and  other  characteristics  of  the  passing 
vehicles  and  people,  a  pretty  shrewd  notion  of  the  commercial 
activity  of  the  population  may  be  formed.  An  observant  for- 
eigner standing  in  Cornhill  and  viewing  the  quick  steady  pace 
and  careful  yet  healthy  faces  of  the  many  classed  wayfarers,  the 
well-packed  loads  of  the  vehicles,  and  their  varied  contents, 
could  not  fail  to  know  that  he  was  in  the  center  of  a  prosperous 
trading  nation.  But  it  would  not  be,  or  ought  not  to  be,  the 
mere  numbers  of  the  people  collected  together  that  suggests  to 
him  the  observation.  On  last  Saturday  he  would  have  seen  a 
greater  crush  than  usual  at  the  same  place,  but  on  inquiry  he 
would  have  found  that  it  was  only  in  consequence  of  all  business 
being  suspended  for  Lord-Mayor's  day.  And  at  Naples,  till 
lately,  the  lazzaroni  and  pickpockets  who  blocked  up  the  pave- 
ments in  the  main  thoroughfares,  were  evidences  of  trade  beinoj 
not  only  suspended,  but  made  impossible  by  a  swarm  of  villians. 
So  that  it  is  not  the  mere  fact  of  crowding  which  should  give 
the  idea  of  wealth. 

In  the  blood  the  physician  traces  proof  of  constructive  meta- 
morphosis (the  city's  manufacturing  industry),  destructive  meta- 
morphosis (its  consumption),  and  effective  life  (its  social  happi- 
ness) being  carried  on.  But  as  our  intelligent  traveler,  in 
estimating  the  wealth  of  a  community,  must  not  be  deceived  by 
an  idle  crowd  at  one  spot,  so  the  medical  philosopher  must  not 
set  down  mere  local  congestion  as  proof  of  wealthy  blood.  In 
both  cases  experience  finds  strong  presumptive  evidence  of  some- 
thing amiss. 

Neither  must  a  mere  bustling  throng  be  reckoned  as  industri- 
ous citizens.  There  are  cases  were  a  larcje  amount  of  solid 
matter,  even  where  a  large  amount  of  red  disks  in  active  motion, 
adds  no  more  to  the  usefulness  of  the  circulating  fluid  than  the 
lazzaroni  to  Naples,  and  which  therefore,  as  far  as  treatment  is 
concerned,  are  really  in  the  same  category  as  obvious  an?emia. 
Of  these  I  shall  take  a  future  opportunity  of  speaking. 


AN.EMIA.  357 

But  though  crowds  are  no  evidence  of  sound  political  health, 
yet  it  is  certain  that  deserted  streets  prove  political  disease.  So 
anaemia,  or  deficient  redness  in  the  blood,  shows  a  deficiency  of 
life  in  the  ministers  to  that  redness ;  either  the  supply  of  food 
is  too  small,  or  its  assimilation  is  defective ;  in  either  case  the 
supply  of  red  disks,  either  absolutely  or  relatively,  is  not  com- 
mensurate with  the  existing  demand. 

In  many  instances  of  anasmia  it  is  easy  enough  to  lay  the 
finger  upon  the  instrument  of  life  which  is  to  blame.  We  detect 
without  difficulty  causes  at  work  to  produce  it — starvation,  which 
anybody  can  understand  leads  to  an  absence  of  the  organic 
matters  made  out  of  food ;  degenerated  stomach,  in  which  the 
aliments  are  not  prepared  for  assimilation  ;  degenerated  liver  and 
duodenum,  producing  the  same  result ;  lesions  of  intestines  or 
their  glands  checking  the  imbibition  of  adipose  matter,  and  so 
preventing  cell  growth  ;  changes  in  the  spleen  or  lungs — organs 
which  our  physiological  experiments,  independent  even  of  our 
observations  of  morbid  phenomena,  show  to  be  answerable  for 
the  formation  of  new  blood-disks  in  a  way  yet  unknown ;  mental 
derangement,  care,  disappointment — which  so  readily  arrests  the 
activity  of  the  assimilating  viscera ;  these  agencies,  and  many 
more,  are  readily  comprehended  as  causes  of  anjBmia.  But  there 
are  many  cases  where  nothing  obvious  of  this  sort  is  to  be  made 
out,  yet  where  the  paleness  of  the  blood  seen  in  the  face,  lips, 
tongue,  or  in  a  drop  taken  from  a  pricked  finger,  and  where  evi- 
dences of  it  in  fainting,  weakness,  palpitation,  anasarca,  amen- 
horrhgea,  &c.,  are  even  more  marked  than  Avhere  demonstrable 
lesion  is  to  be  found.  So  it  is  in  the  present  instance.  The 
young  woman's  history  gives  no  reason  to  suspect  any  organic 
disease  of  the  lungs  or  other  organs,  and  the  functions  of  life 
were  fairly  performed  till  she  began  to  get  pale  and  languid 
nine  months  ago.  The  want  of  red  blood,  which  we  look  upon 
as  the  important  feature  in  her  case,  also  attracted  her  own 
attention  particularly,  as  she  had  previously  had  an  ornamental 
fresh  color.  Then,  after  an  interval  amply  sufficient  to  enable 
us  to  separate  cause  and  effect,  come  the  symptoms  which  I  wish 
to  notice  as  the  consequences  of  antemia.     Causes,  no  doubt, 


358  ANEMIA. 

they  are  in  some  instances,  but  here  consequences.  I  mean  the 
loss  of  appetite,  impeded  circuhition,  amenorrlisea,  and  hemor- 
rhage from  the  respiratory  organs  in  a  person  previously  unaf- 
fected in  that  way,  which  are  noticed  in  the  case  book. 

The  only  explanation  she  can  give  of  her  loss  of  health  is  her 
having  been  employed  in  a  shop  less  perfectly  ventilated  than 
she  had  been  used  to,  and  having  the  main  responsibility  of  the 
concern  thrown  upon  her.  Alone  neither  would  have  been  suf- 
ficient, as  the  shopwomen  under  her  do  not  appear  to  have  suf- 
fered from  the  air ;  while,  on  the  other  hand,  women  engaged  in 
retail  business  are  not  as  a  rule  ansemic.  But  still  I  think  that 
both  together  may  perhaps  be  fairly  charged  with  the  blame,  for 
while  the  increased  mental  labor  was  increasing  metamorphosis, 
the  greater  demand  was  not  responded  to  by  greater  supply,  but 
on  the  contrary  assimilation  was  checked  by  the  comparative 
unwholesomencss  of  the  respired  air. 

The  not  being  able  to  trace  deeper  the  anatomical  cause 
arises  from  the  imperfection  of  our  knowledge,  but  it  does  not 
arise  from  neglecting  to  apply  such  knowledge  as  we  possess  to 
practical  medicine.  If  we  were  to  make  an  autopsy  of  this 
patient  instead  of  curing  her,  we  should  in  all  likelihood  see 
no  more  solid  lesions  capable  of  accounting  for  her  disease  than 
we  already  know  of,  we  should  probably  find  nothing  abnormal 
in  any  part.  So  that  you  need  not  lament  the  opacity  of  your 
patients'  bodies,  or  suppose  yourselves  likely  to  learn  how  to 
treat  them  better  if  you  could  see  their  insides. 

Anaemia  without  obvious  organic  lesion  of  the  solids,  when 
properly  managed,  is  a  very  curable  condition,  and  this  should 
still  further  reassure  you  that  you  miss  nothing  by  not  being 
able  to  study  its  post-mortal  pathology.  For  passing  and  cura- 
ble states  leave  but  faint  footprints  behind  them  for  anatomists. 
In  a  great  majority  of  cases  they  depend  upon  morbid  changes 
of  the  mucous  membrane,  of  all  the  tissues  in  the  body  the  one 
most  speedily  affected  by  decomposition  after  death,  and  then 
presenting  the  worst  possible  picture  of  its  condition  during 
life. 

The  intestines,  as  the  anatomist  sees  them,  are  about  as  much 


ANEMIA.  359 

like  the  intestines  in  health  as  the  crumpled  folds  of  dank 
parchment  Avhich  surround  the  mouth  of  a  corpse  resemble  the 
same  lips  swelling  with  joy  and  expression. 

Let  the  picture  which  is  painted  on  our  minds  be  taken,  not 
from  the  dead  house,  but  from  the  familiar  view  of  our  own 
mouths  in  a  looking-glass  ;  for  one  sketch  drawn  from  the  life 
is  worth  ten  fiom  the  museum.  Turn  down  the  lower  lip,  and 
observe  the  infinite  life  going  on.  There  is  evidently  as  much 
blood  as  vessel ;  and  seeing  that  blood,  from  the  quantity  of 
solid  matter  visible  in  it,  has  a  right  to  be  called  a  semi-solid, 
this  membrane  has  an  equal  right  to  be  thought  of  as  a  semi- 
fluid. And  when  we  think  of  it  as  semi-fluid,  let  not  the  idea 
of  a  stagnant  marsh  be  presented  to  us,  but  of  a  headlong 
rapid. 

It  is  a  useful  way  of  keeping  lively  our  feelings  about  the 
circulation,  to  examine  through  the  microscope  occasionally  the 
toe-web  of  the  slow-blooded  frog.  The  action  and  ceaseless 
whirl  of  the  living  stream  we  see  there  quite  drives  us  dizzy. 
What  then  must  it  be  in  our  own  Avarm  selves !  If  in  a  mem- 
brane so  little  animated  as  the  frog's  toe,  or  the  bat's  wing, 
which  by  the  naked  eye  we  should  judge  to  be  entirely  devoid 
of  blood,  we  are  still  enabled  by  our  microscopes  to  see  such  a 
network  of  tubes  conveying  it — if,  in  a  creature,  the  greater 
part  of  whose  blood  is  driven  from  the  extremities  to  the  center 
by  the  tempoi'ary  flight  Ave  cause  in  putting  him  under  a  micro- 
scope, we  find  such  a  busy  scene  of  circulation — what  must  be 
going  on  in  a  tissue  glowing  with  red  life  and  health  ! 

To  the  fault  of  the  mucous  membranes  I  am  disposed  to  lay 
the  condition  in  which  we  find  our  present  patient.  The  t.vo 
circumstances  to  which  I  have  traced  the  illness  both  act  directly 
or  iudiiectly  on  this  tissue.  The  mental  exertion  involved  in 
an  unwonted  responsibility  thrown  on  a  conscientious  person 
would  lessen  the  life  of  the  involuntary  muscles  which  carry 
along  the  mass  of  food  through  the  alimentary  canal.  You 
know  well  how  long  your  food  is  in  leaving  the  stomach  if  you 
are  called  to  an  important  midwifery  case  just  after  a  hearty 
meal;  and  several  commercial  and  literary  men  have  complained 


360  ANiEMIA. 

to-  me  of  attacks  of  vomiting  (that  is,  temporary  paralysis  of 
the  stomach)  when  they  took  dinner  alone,  and  so  were  apt  to 
let  the  mind  dwell  deeply  on  some  interesting  subject ;  and 
they  have  told  me  in  wonder  that  they  could  dine  out  and 
eat  and  drink  all  sorts  of  rich  things  with  impunity.  They 
did  not  seem  aware  of  the  preservative  value  of  frivolous  con- 
versation. 

At  the  same  time  that  the  moral  causes  thus  impeded  diges- 
tion, the  unwholesomeness  of  the  air  in  the  close  shop  where 
our  patient  was  employed  poisoned  the  mucous  membranes, 
diminishing  the  vitality  of  their  epithelium,  and  causing  them  to 
be  abnormally  covered  with  a  thick  layer  of  mucus.  By  this 
tenacious  coating  the  entrance  of  alimentary  substances  into  the 
veins  and  absorbents  was  impeded,  and  the  owner  pined  in  the 
midst  of  plenty.  So  all  the  usual  signs  of  starvation  followed. 
First,  hunger, — by  no  means  a  constant  companion  of  chronic 
deprivation  of  food,  yet  sometimes  present  as  here  ;  then  loss 
of  appetite,  a  much  more  frequent  phenomenon ;  then  paleness, 
languor,  weariness,  and  pain  in  the  stomach  ;  then  anasarcous 
oedema,  and,  in  short,  the  other  more  marked  symptoms  of 
anaemia. 

You  may  observe  that  the  loss  in  those  constituents  of  the 
body  which  are  of  a  nitrogenous  chemical  composition,  is  more 
marked  than  that  in  the  hydro-carbonaceous  fat.  The  reason 
is  partly  that  the  destruction  of  adipose  vesicles  is  somewhat 
shrouded  by  the  saturation  of  the  tissue  with  serum,  which  gives 
it  a  false  plumpness — partly  that  fat,  being  absorbable  without 
much  (if  any)  alteration,  is  easier  taken  up  into  the  system  than 
fibrin  or  albumen,  which  require  a  chemical  solution  before  they 
can  be  absorbed.  So  that,  though  starved,  Margaret  looks  but 
little  emaciated. 

All  that  I  have  now  said  must  have  of  course  for  its  moral  some 
hints  on  the  treatment.  My  aim  in  ansemia  is  to  introduce  as 
quickly  as  I  can  the  largest  possible  amount  of  (1)  nitrogenous 
food,-  (2)  iron,  (3)  chlorine.  When  I  say  "introduce,"  I  do  not 
mean  "  throw  in,"  or  get  swallowed,  but  cause  to  be  assimilated 
in  the  system. 


ANiEMIA.  361 

As  regards  the  first,  it  is  obvious  that  if  I  had  written  down 
ever  so  many  "ordinary  diets,"  one  to  whom  the  very  sight  of 
food  was  an  abomination  would  have  gained  nothing  by  it ;  she 
would  simply  have  gone  without.  I  directed  no  meals  at  all  to 
be  taken,  and  no  solid  food ;  but  a  cup  of  milk  with  a  third  part 
of  lime-water  in  it  to  be  given  as  medicine  every  two  hours,  and 
a  pint  of  beef-tea  in  divided  doses  during  the  day.  After  two 
days  she  managed  to  eat  an  egg  also  daily,  and  after  twelve  days 
of  gradual  additions  of  this  sort,  you  will  find  her  on  full  allow- 
ance of  mutton-chops,  porter,  beef-tea  and  milk. 

Iron  is  required  to  supply  the  anticipated  new  growth  of  red 
disks  with  their  metallic  constituent.  You  cannot  force  into  the 
system  in  any  way  so  certainly  as  by  the  "  mistura  ferri  com- 
posita"  of  the  pharmacopoeia.  Large  doses  of  the  more  soluble 
salts  of  iron  have  an  action  on  the  mucous  membranes  which 
not  only  prevents  their  being  taken  up,  but  only  checks  the 
digestion  of  other  food.  Evidence  of  the  last-named  effect  is 
found  in  loss  of  appetite  and  feverishness,  and  in  the  rejection 
of  iron  and  undigested  food  among  the  blackened  stools  much 
sooner  than  when  the  metal  is  given  in  the  form  named.  In 
spite  of  the  elegance  of  preparations  constantly  put  before  us, 
and  recommended  for  their  solubility,  such  as  the  chloride, 
acetate,  citrate,  phosphate,  and  other  salts  of  iron,  I  often  pre- 
fer the  unchemical  mixture.  It  seems  as  if  the  carbonate  which 
is  preserved  from  decomposition  by  the  sugar,  and  the  finely 
divided  oxides  diffused  through  the  thick  liquid,  were  peculiarly 
easy  of  solution  in  the  water  saturated  with  salts  and  carbonic 
acid,  the  solvent  with  which  we  have  to  do,  not  only  in  the 
stomach,  but  throughout  the  whole  body. 

In  reckoning  the  solubility  of  medicines,  physiological  phar- 
maceutists are  apt  to  count  the  fluids  of  the  body  as  distilled 
water,  and  because  a  substance  is  not  soluble  in  that  medium, 
to  call  it  insoluble  altogether  ;  whereas,  if  it  be  soluble  in  water 
saturated  with  carbonic  acid  and  salts,  it  is  sufficiently  soluble 
for  the  purposes  of  life. 

I  have  found  that  some  cases  which  did  not  get  on  so  fast  as 
I  could  wish  under  the  above  treatment,  made  a  sudden  start 


362  ANEMIA. 

of  improvement  when  to  it  there  was  added  the  administration 
of  clilorine  in  the  form  of  warm  hydrochloric  acid  baths.  More 
iron  is  taken  up,  the  blackening  of  the  faeces  ceases,  and  it  may 
be  that  the  presence  of  more  acid  in  the  system  retains  more  of 
the  metal.  In  a  few  cases  I  tried  for  experiment's  sake  the 
hydrochloric  acid  baths  alone ;  and  even  then  it  was  beneficial, 
seeming  to  confer  muscular  strength  in  the  same  way  as  the 
articles  of  materia  medica  which  are  commonly  called  tonic.  On 
these  grounds  I  cannot  but  think  that  hydrochloric  acid  supplies 
a  distinct  want  in  the  system,  that  it  is  a  directly  restorative 
medicine  in  anaemia. 

It  is  not  difficult  to  make  this  empirical  observation  accord 
with  rational  pathology.  In  anaemia  the  blood  is  more  watery 
than  natural ;  the  proportion  not  only  of  organic  matters  but  of 
salts  is  deficient.  Chloride  of  sodium  is  the  most  important  of 
these  salts,  and  the  supply  of  one  of  the  constituents  of  this  ma- 
terial may  be  without  fancifulness  conjectured  to  be  an  aid  to 
that  renewal  of  life,  which  is  the  end  of  all  medication. 

Besides  the  above-named  medicines,  you  see  that  I  have  pre- 
scribed Pil.  aloes  cum  myrrlid  gr.  iv.  omni  node  sumenda.  Do 
not  suppose  that  this  is  ordered  merely  as  a  purgative,  or  that 
any  other  purgative  would  do  as  well.  On  the  contrary,  most 
purgatives  are  injurious  in  anaemia.  Gamboge,  sulphate  of 
magnesia,  colocynth,  mercury,  and  several  others  which  prodjice 
elimination  of  serum  and  increase  secretion  generally,  do  harm 
just  in  proportion  to  their  activity.  It  seems  established,  by 
the  experiment  of  making  them  act  as  purgatives  when  injected 
into  the  circulation,  that  their  soluble  principles  have  a  destruc- 
tive iigency  upon  the  blood;  whereas  the  soluble  alkaloid  in 
aloes  (aloine)  is,  in  fact,  a  bitter  tonic,  and  the  purgative  power 
of  the  vegetable  resides  in  its  insoluble  resin.*  Its  action  is  very 
moderately  eliminative — in  small  doses  it  slightly  adds  to  the 
solid  excreta  of  the  colonic  glands,  and  elicits  faeces  feculent  in 
smell  and  of  consistent  form— while  at  the  same  time  it  retains 
by  its  bracing  bitter  the  formation  of  mucus.      See  its  action  on 

*  See  Headland  on  the  "  Action  of  Medicines,"'  p.  331  ;  ani  Robifiuet,  in  the 
"Journal  de  Pbarmacie"  for  April,  185G,  quoted  by  Dr.  Headland. 


ANAEMIA.  363 

moist  piles,  how  it  dries  them  up  and  makes  them  smart !  And 
judge  from  this  what  its  action  on  tlie  gastro- intestinal  raucous 
membrane  is  likely  to  be.  At  the  same  time  by  the  more 
vigorous  peristaltic  action  and  by  the  solid  mass  passed  along 
the  gut,  the  already  existing  mucus  is  cleared  away.  Aloes  is 
employed  strictly  as  a  clearer  of  the  intestinal,  especially  of  the 
colonic,  membrane,  and  it  is  joined  with  myrrh,  partly  to  divide 
it  minutely  and  make  a  small  dose  go  further,  and  partly  to  get 
the  advantage  of  the  extra  resin. 


(Part  II. — Clinical,  St.  Marys,  January  23,  1863.) 

In  a  young  unmarried  woman,  who  leaves  the  hospital  to-day, 
you  may  see  an  example  of  an  occasional  effect  of  anaemia  to 
which  I  have  not  hitherto  called  your  attention,  I  mean  its  effect 
on  the  mental  faculties. 

Margaret  H.,  aged  nineteen,  a  stout  and  well-made,  but  small- 
boned,  girl  from  the  city  of  Cork,  was  admitted  at  Christmas  with 
pallor,  palpitation  of  heart,  oedema  of  ankles,  loss  of  appetite, 
amenorrhoea,  and  some  other  of  the  usual  s^^mptoms  of  anoemia 
without  organic  disease.  She  was  not  at  all  hysterical.  She 
stated  that  she  had  been  eight  months  in  London  engaged  as  a 
maid-of-all-Avork,  and  attributed  her  present  illness  to  the  hard 
labor  entailed  by  that  situation.  She  was  ordered  food  every 
two  hours  and  Griffiths'  steel  mixture  thrice  daily,  and  has  been 
taking  the  latter  up  to  the  present  time  with  the  usual  improve- 
ment to  her  health.  So  far  she  exactly  resembles  a  class  of 
cases,  of  which  we  admit  two  or  three  every  week. 

The  only  peculiarity  Avas  her  excessive  sluggishness  of  body 
and  mind.  She  would  lie  or  sit  for  hours  without  moving  in 
the  posture  she  was  placed  in  ;  and  if  desired  to  walk  dragged 
herself  along  like  a  sloth.  If  questioned  she  did  not  answer,  or 
confined  her  reply  to  rigid  monosyllables.  This  slowness  of  ner- 
vous and  intellectual  power  remained  even  after  she  had  begun 
to  regain  color  in  her  lips  and  cheeks ;  so  that  the  sister  and 
nurses  set  her  down  as  naturally  half-witted,  and  doubted  the 


364  ANEMIA. 

possibility  of  her  gaining  her  livelihood  as  a  servant  even  in  the 
hun^blest  capacity.  As  she  possesses  more  than  ordinary  perso- 
nal attractions,  I  dreaded  sending  out  such  a  simple-minded 
creature  defenceless  into  the  wicked  world  of  London.  But 
during  the  last  week  some  accident  has  set  her  to  work  at  crot- 
chet, and  I  found  her  fingers  nimbly  twinkling  at  this  occupation, 
which  it  seems  she  had  been  accustomed  to  in  Ireland.  She  was 
encouraged  to  proceed,  and  to  our  surprise  the  manual  operation, 
monotonous  and  mechanical  as  it  seems  to  us,  acted  like  magic ; 
in  a  few  days  she  became  cheerful,  laughs  and  talks  to  the  pa- 
tients, and  has  turned  out  a  brisk  girl  of  more  than  average  in- 
telligence. In  consequence  one  of  our  hospital  visitors  has 
proposed  to  get  her  a  place  as  lady's  maid. 

Doubtless  the  way  was  prepared,  by  the  action  of  the  iron  in 
curing  the  anaemia,  for  a  very  slight  extra  restorative  agent  to 
enable  her  to  regain  her  mental  powers.  Still  I  cannot  but  at- 
tribute very  considerable  influence  to  the  habitual  occupation, 
associated  as  it  is  with  memories  of  her  former  happier  life, 
taking  her  thoughts  away  from  the  dark  back-kitchen  of  a  Lon- 
don shop  to  the  old  merry  days  in  county  Cork. 

There  were  here  two  deficiencies  to  be  restored; — first,  that 
of  red  globules  in  the  blood,  which  was  effected  by  food  and 
iron  in  the  manner  I  have  so  often  explained  to  you; — and 
secondly,  that  of  the  mental  faculties;  some  new  and  brighter 
associations  were  required  to  excite  her  voluntary  nervous  system 
to  action  and  to  break  the  dull  chain  of  her  daily  routine.  Acci- 
dent supplied  this  in  the  present  patient's  case,  and  with  such 
good  effect,  and  so  strikingly,  that  I  trust  you  may  be  led  to 
make  your  reason  in  other  cases  take  example,  and  do  inten- 
tionally what  was  here  done  by  a  lucky  chance.  Occupation, 
and  that  not  merely  of  an  amusing  character,  but  of  suflBcient 
interest  and  importance  to  require  constant  attention,  is  often  a 
most  valuable  aid  to  treatment.  I  have  known  the  little  house- 
hold duties  which  are  a  woman's  functon,  even  needle-work 
which  must  be  done  by  a  certain  time,  such  as  making  a  pair  of 
slippers  for  their  doctor,  have  a  most  beneficial  effect  upon  the 
weakened  mind. 


AN.^MIA.  365 

(Part  III. — Clinical,  St.  Marys,  February  6,  1864.) 

The  cases  entered  as  ansemia  in  the  register  are  usually  such 
as  do  not  display  signs  of  any  organic  lesion  to  account  for  the 
deficient  supply  of  red  blood  to  the  tissues.  And  the  knowledge 
that  these  patients  are  readily  cured  by  iron  is  so  familiar  to 
you  that  it  seems  almost  like  a  truism.  I  am  not  sure  if  you 
equally  entertain  the  fact  that  the  same  treatment  is  not  less 
applicable  to  those  whose  defect  is  explained,  either  mechanic- 
ally or  physiologically,  by  some  discovered  structural  change  of 
a  permanent  nature.  You  are  too  apt  to  look  upon  this  struc- 
tural change  as  the  main  point  to  be  considered,  and  in  conse- 
quence, where  it  happens  to  be  irremovable,  you  do  not  pay 
sufficient  attention  to  such  results  of  it  as  are  really  quite  sus- 
ceptible of  cure. 

To  illustrate  my  words  I  will  call  to  your  recollection  a  young 
woman  who  has  just  left  the  hospital.  On  January  8,  Louisa  0., 
an  unmarried  servant,  aged  twenty-five,  was  obliged  to  be  sent 
up  to  bed  with  ansemia  of  very  marked  character.  There  was 
not  a  trace  of  red  in  her  cheeks  or  lips  even  under  the  influence 
of  excitement.  She  was  hardly  able  to  stand  upright,  and  the 
attempt  to  do  so  brought  on  great  faintness  and  giddiness.  The 
catamenia  which  last  flowed,  though  at  the  regular  time,  were 
of  a  greenish  color.  She  had  palpitation  of  the  heart,  and  had 
been  getting  paler  for  several  weeks,  but  the  inability  to  stand 
was  only  of  a  fortnight's  duration.  There  was  pain  complained 
of  in  the  cardiac  region,  and  a  loud  blowing  murmur  was  to  be 
heard  with  the  first  sound.  This  blowing  murmur  was  very 
audible  all  over  the  cardiac  region,  and  up  the  large  vessels  into 
the  neck,  but  loudest  and  of  a  harsher  character  than  elsewhere 
just  at  the  level  of  the  aortic  valves.  She  could  give  no  history 
of  rheumatism,  but  had  scarlatina  some  years  ago.  She  was 
treated  with  iron  mixture  every  three  hours,  and  beef-tea  and 
milk  every  t\vo  hours.  On  the  13th  she  was  able  to  eat  a  mutton 
chop.  On  the  16th  the  lips  were  getting  rosy,  and  she  was  able 
to  color  up  when  spoken  to.  By  the  27th  she  had  gained  a  very 
24 


366  AN.EMIA. 

fair  color,  even  when  not  blushing,  and  she  was  discharged  on 
the  29th.  But  the  cardiac  murmur  remained  as  loud,  if  not 
louder,  and  was  equally  ringing  in  its  tone  at  the  level  of  the 
aortic  valves.  She  went  home  registered  as  "cured"  (for  it  had 
been  indexed  as  a  case  of  "  anaemia,")  was  supplied  with  a  large 
bottle  of  her  mixture,  and  was  advised  every  two  or  three  months 
to  take  a  ten  days'  course  of  iron  in  some  form.  She  was  warned 
also  that  mercury,  purgatives,  antimony,  and  all  debilitating 
medicines  were  very  bad  for  her  constitution,  and  that  she  must 
request  any  medical  man  whom  she  might  consult,  not  to  give 
them  to  her. 

I  have  no  doubt  in  my  own  mind  that  this  patient's  central 
organ  of  circulation  is  in  an  imperfect  condition  ;  and  the  special 
auscultatory  signs  induce  me  to  think  that  the  imperfect  con- 
dition consists  of  a  narrowness  of  the  aortic  orifice.  It  is  true 
that  she  has  never  had  any  of  the  illnesses  which  usually  cause 
cardiac  lesion,  and  therefore  I  do  not  suppose  the  lesion  to  be 
of  a  degenerative  kind.  I  should  conjecture  it  to  have  more  of 
the  nature  of  an  arrest  of  development.  She  is  a  puny,  incom- 
plete person,  of  slim  figure,  with  narrow  hips  and  hardly  any 
bust,  with  fine  soft  hair  and  a  delicate  skin.  Though  turned  of 
twenty-five,  she  has  the  aspect  of  seventeen.  I  think  it  very 
likely  that  the  aorta  and  its  valves  have  not  grown  with  her 
growth,  but  still  retain  the  caliber  suitable  for  a  young  girl. 
She  is  consequently  unable  to  do  woman's  work ;  and  even  the 
usual  monthly  discharge  from  the  uterus,  which  is  a  relief  to  the 
fully  formed  female  body,  is  too  much  for  her.  For  the  supply 
of  blood  to  support  work  is  limited  by  the  limitation  of  area 
through  which  it  has  to  pass. 

Whether  the  aorta  will  ever  make  up  for  lost  time,  and,  though 
late,  accommodate  itself  to  the  body,  I  cannot  tell.  But  I  can 
tell  by  the  results  of  this  and  similar  cases  that  the  watery  blood 
is  capable  of  renewal,  though  it  be  watery  in  consequence  of  a 
still  existing  cause.  And  if  any  agent  ever  removes  that  still 
existing  cause,  by  renewing  its  imperfect  life,  I  am  sure  that 
agent  will  be  healthy  human  blood,  the  best  medicine  ever  de- 
vised. 


ANiEMIA.  367 

The  warnino;  I  o-ave  her  was  directed  ajjainst  an  unfortunate 
tendency,  common  to  both  the  public  and  our  profession,  towards 
commencing  treatment  habitually  with  destructive  remedies. 
They  call  this  "clearing  the  decks  for  action;"  in  a  majority  of 
instances  they  throw  overboard  much  of  the  best  tackling  in  the 
ship  and  loosen  her  armor-plates.  A  so-called  "sluggishness  of 
the  liver"  is  a  frequent  pretext.  In  a  half-nourished  person 
with  pale  blood  of  course  the  faeces  are  apt  to  be  light-colored 
and  scanty.  Blue  pill  gives  them  immediately  a  darker  color 
and  increases  their  quantity,  sadly  at  the  cost  of  the  patient's 
strength,  and  the  temporary  change  soon  passes  off.  Meat  and 
iron  produce  the  same  result,  by  giving  them  more  to  be  made 
out  of,  and  the  improvement  is  a  real  and  permanent  one. 


LECTURE   XXVII I. 

PROMINENCE    OF    EYEBALLS. 

Cases  with  commentaries — Tlie  'pathology  of  the  disease  associ- 
ated u'ith  that  of  ansemia,  and  (he  requisite  treatment  tlience 
deduced. 

{Clinical,  St.  Marys,  May  2,  1863.) 

A  YOUNG  woman  who  left  the  hospital  yesterday  exhibits  one 
of  the  occasional  accompaniments  of  anoemia  in  a  marked  degree. 
She  is  a  subject  of  that  state  of  the  eyes  called  (somewhat  bar- 
barously) Exophthalmia  or  Exophthalmos. 

Emily  M.,  aged  twenty-three,  spinster,  had  been  in  since 
April  the  10th.  She  is  a  leucophlegmatic  flaxen-haired  girl, 
but  tall  and  well-grown,  "with  great  marble  limbs."  Her  com- 
plaint was  menorrhagia,  which  had  begun  a  month  before  by  a 
slight  attack  of  hasmoptysis.  Of  this  she  was  soon  relieved  by 
an  ounce  of  infusion  of  digitalis  three  times  a  day,  a  grain  of 
opium  every  night,  and  complete  rest  in  bed;  and  I  am  not  going 
to  lecture  on  that  subject  now.  She  has  had  two  attacks  of 
rheumatic  fever,  the  first  when  a  child,  the  last  two  years  ago. 
Four  years  ago  she  had  measles  rather  severely,  and  since  that 
date  her  eyes  have  gradually  got  very  prominent.  The  promi- 
nence vaiies  somewhat  with  her  state  of  health,  and  on  her  ad- 
mission was  worse  than  usual.  The  left  eye  squinted  disagreeably 
outwards,  as  is  usually  the  case  when  she  is  in  her  worst  state  of 
health.  On  gently  applying  firm  pressure  with  the  fingers  to  the 
eyeballs,  they  may  be  got  back  to  their  natural  place  in  the 
sockets,  and  at  the  same  time  the  cellular  tissue  beneath  the 
lower  eyelid  swells  out. 

There  is  slight  dullness  on  percussion,  accompanied  by  bron- 


PROMINENCE  OF  EYEBALLS.  369 

chial  breathing,  below  the  right  clavicle.  There  is  a  loud  sys- 
tolic murmur  in  the  heart,  much  most  marked  at  the  level  of  the 
aortic  valves,  and  not  affected  by  change  of  posture. 

This  prominence  of  the  eyeballs  is  a  patholgical  problem  not 
yet  at  all  satisfactorily  solved.  There  are  four  ways  in  which 
it  has  been  accounted  for — first,  by  describing  it  as  an  enlarge- 
ment of  the  eyeball  itself,  a  view  advocated  by  Drs.  Begbie  and 
Stokes; — second,  by  its  protrusion  in  consequence  of  hyper- 
trophy of  the  tissues  at  the  back  of  the  orbit,  as  is  maintained 
by  Dr.  Basedow; — third,  by  a  congestion  and  dropsical  swelling 
of  the  same  tissues,  accompanied  by  want  of  tone  in  the  ocular 
muscles,  to  which  Mr.  Cooper  ascribes  it; — fourth,  by  an  in- 
crease of  the  fat  which  forms  the  padding  of  the  globe,  which 
Dr.  Ileusinger  has  found  in  two  post-mortem  examinations. 
These  different  views  are  described  and  enlarged  upon  in  the 
"Edinburgh  Medical  and  Surgical  Journal"  for  1854,  page 
426,  where  you  will  find  full  references  to  the  literature  of  the 
subject. 

The  first  explanation  certainly  can  apply  only  to  exceptional 
cases.  In  three  at  present  under  my  care  no  enlargement  of 
the  prominent  organ  can  be  detected;  nor  in  two  patients  I  saw 
cursorily  several  years  ago,  do  I  remember  to  have  observed  it. 
Indeed,  in  the  girl  whose  history  I  have  just  related,  the  globes 
are  both  rather  small  for  one  of  her  height  and  size.  I  can 
hardly  imagine  a  tough,  leathery  sac,  like  the  eyeball,  swelling 
without  a  local  disease  of  its  coats,  such  as  cancerous  degenera- 
tion for  example ;  and  that  would  produce  a  disease  of  quite 
another  class,  and  not  to  be  confounded  with  the  subject  of  this 
lecture.  "  Hypertrophy  "  of  the  tissues  at  the  base  of  the  orbit, 
suggested  by  Dr.  Basedow,  would  imply  a  persistent  and  ir- 
remediable condition ;  whereas  I  am  sure  that  the  eyes  are  at 
some  times  more  prominent  than  at  others,  and  that  consider- 
able improvement  may  take  place. 

My  own  impression  is  that  the  slighter  and  incipient  cases 
may  be  quite  accounted  for  by  relaxation  of  the  muscles,  and 
that  would  soon  be  increased  by  a  consequent  filling  up  of  the 
tissue  by  fluid  and  congested  vessels.     I  incline  therefore  to  the 


370  PROMINENCE  OF  EYEBALLS. 

opinion  given  hj  Messrs.  Cooper  and  Dalrjmple,  who  attribute 
the  disease  to  this  cause. 

At  the  same  time  it  must  be  observed  that  Dr.  Heusinger 
supports  his  opinion  as  to  its  dependence  on  an  increase  of  fat 
in  the  post-ocukir  space  by  two  post-mortem  examinations,  in 
which  he  found  that  condition  of  things.  And  I  do  not  see  any 
inconsistency  in  supposing  that  while  the  lighter  cases  are  ex- 
plicable in  the  way  I  have  first  advocated,  the  fatal  and  more 
protracted  should  exhibit  a  more  permanent  morbid  change. 
The  deposit  of  fat  in  the  tissue  is  quite  analogous  to  what  takes 
place  in  parts  which  have  been  stretched  or  temporarily  enlarged, 
sueh  as  in  the  mammse  or  abdominal  parietes  after  frequent 
pregnancies,  in  old  hernial  sacs,  in  the  scrotum  after  long  con- 
tinued varicosity  of  the  veins,  in  the  ear  and  lips  after  they  have 
been  unnaturally  stretched  in  accordance  with  savage  ideas  of 
ornament. 

I  mentioned  having  two  other  cases  now  under  my  care.  As 
it  is  rather  a  rare  disease,  I  shall  take  the  liberty  of  breaking  my 
usual  law  for  clinical  lectures  and  of  relating  their  histories, 
though  I  cannot  enable  you  to  verify  them  for  yourselves, 
Mary  B.,  a  surgeon's  daughter  now  aged  thirty,  first  came  to 
me  in  June  last  year.  She  had  been  for  several  years  the  un- 
remitting nurse  of  an  invalid  mother,  and  restricted  from  the 
enjoyments  almost  essential  to  the  health  of  her  age  and  sex. 
For  three  years  the  catamenia  had  been  irregular,  and  some- 
times absent  for  several  months  at  a  time.  Her  face  and  lips 
were  pale,  and  her  skin  fair  and  delicate,  easily  flushing  with 
excitement.  Six  months  previously  she  had  a  severe  pain  in  the 
region  of  the  heart,  and  her  doctor  told  her  it  was  "rheumatism 
of  the  heart,"  and  she  had  also  suffered  from  palpitations. 
About  that  time  she  began  to  perceive  a  prominence  of  the 
eyeballs,  and  this  had  gradually  become  so  marked  as  to  make 
her  uncomfortable  by  the  observations  it  excited  among  her 
acquaintance. 

Examination  of  the  chest  showed  the  lungs  to  be  quite  healthy. 
The  action  of  the  heart  was  sharp,  and  there  was  a  short  harsh 


PROMINENCE  OF  EYEBALLS.  371 

scrape  audible  towards  the  end  of  the  first  sound  at  the  level  of 
the  aortic  valves. 

I  ordered  her  to  take  an  ounce  of  the  following  mixture  twice 
a  day : 

I^    Tincturse  ferri  sesquichloridi  5'j, 
Stryclinix  liydrochlorath  gr.  J, 
Tincturse  digitalis  5j, 
Mistui'se  camphorse  5x, 
Fiat  mistiira,  cujus  swnantur  cochlearia  ij  maxima  his  die. 

I  kept  her  in  London  a  few  weeks  as  a  rest,  and  since  then 
she  has  taken  every  two  months  a  three  weeks'  course  of  the 
medicine.  She  sends  me  word  that  now  with  the  improvement 
of  her  general  health  the  eyes  have  become  much  less  prominent, 
and  that  she  is  by  no  means  remarkable  in  her  appearance. 

The  other  case  is  that  of  a  puny  woman  of  about  fifty,  who 
says  she  has  been  always  ailing  all  her  life,  but  never  quite  ill. 
She  is  the  subject  of  a  goitre  of  the  central  part  and  right  lateral 
lobe  of  the  thyroid  gland.  There  is  also  a  good  deal  of  palpi- 
tation of  the  heart,  but  I  cannot  satisfy  myself  of  the  existence 
of  any  decided  mui'mur.  She  is  a  very  timid  nervous  person, 
and  has  some  sort  of  fits,  probably  of  an  hysterical  nature.  I 
gave  her  iodide  of  potassium,  and  applied  iodine  externally  to 
the  tumor  of  the  throat.  But  after  three  weeks  it  was  but  little, 
if  at  all,  reduced,  and  she  felt  sure  that  her  general  health  was 
the  worse  for  the  treatment.  So  then  I  gave  her  iron  in  full 
doses,  and  she  seemed  stronger  again.  She  was  at  this  con- 
juncture much  thrown  back  by  the  alarm  occasioned  by  a  fire  in 
her  house.  Her  eyes  are  no  better,  but  she  is  an  unsatisfactory 
patient,  and  I  question  whether  she  perseveres  in  her  medicine. 

Another  case  came  under  my  care  in  the  hospital  during  the 
first  week  of  1859  :* 

Charlotte  B.,  aged  thirty-nine,  a  dressmaker,  had  been  in 
poor  health  for  more  than  three  years,  and  had  always  been  a 
•weakly  creature^  of  pale  leucophlegmatic  aspect.  At  the  period 
named  a  swelling  about  as  big  as  an  egg  came  in  the  front  of  the 

*  See  Case  Book  XIX,  p.  95. 


372  PROMINENCE  OF  EYEBALLS. 

throat.  It  was  hard  and  had  increased  in  size  gradually  to  that 
of  nearly  three  eggs  at  the  time  of  admission.  Latterly  there 
had  been  strong  pulsation  in  it,  and  it  had  caused  occasional 
dyspnoea,  for  which  leeches  had  been  applied  a  week  previously, 
with  temporary  relief.  She  was  hysterical  and  had  a  nervous 
cough  of  a  spasmodic,  noisy  character.  Both  eyes  were  ex- 
cessively prominent,  and  this  prominence  she  said  had  first  been 
observed  a  year  before,  and  had  increased  up  to  admission. 

I  cannot  tell  you  much  more  about  this  case,  as  I  was  just 
then  obliged  to  go  abroad,  but  she  is  shown  by  the  register  to 
have  left  the  hospital  at  Lady-day,  and  has  not  been  again  ad- 
mitted. She  has  attended  from  time  to  time,  however,  as  an 
out-patient,  and  finds  the  occasional  course  of  steel  she  gets 
beneficial,  or  she  would  not  come  for  more.  I  have  seen  her 
about  in  the  neighborhood,  and  her  eyes  seem  no  worse. 

All  these  cases,  and  indeed  all  the  cases  recorded  by  various 
authors,  so  ably  collected  by  Dr.  Begbie,*  however  much  they 
may  diifer  in  minor  details,  agree  in  connecting  the  disease  with 
ansemia,  and  especially  with  those  tendencies  in  ansemia  to  dis- 
order the  heart  and  the  growth  of  the  thyroid  gland.  Experi- 
ence seems  to  refer  the  goitre,  the  weakened  heart,  and  the  pro- 
trusion of  the  eyeballs,  to  the  same  motive  causes.  They  may 
not  be  connected  with  one  another,  but  they  are  all  connected 
with  ansemia. 

Although,  therefore,  the  direct  mechanism  by  which  the  eye- 
ball is  pushed  outwards  may  be  obscure,  it  seems  to  me  that  we 
know  enough  about  the  ailment  to  be  quite  satisfied  as  to  the 
right  treatment,  the  most  important  point  for  both  the  patient 
and  ourselves.  Courses  of  steel  and  restorative  diet,  rest  of 
body  and  ease  of  mind,  are  the  most  effectual  means  of  recovery, 
and  seem  to  have  been  adopted  by  all  those  who  have  mentioned 
their  treatment  in  the  histories  they  put  on  record. 

In  addition  to  this  I  should  direct  the  patient  to  gently  press 
back  the  eyeballs,  and  to  wear  a  bandage  over  them  at  night. 

We  know  enough  about  the  ailment  also  not  to  be  alarmed  at 

*  Begbie's  "Contributions  to  Practical  Meditine,"  1862. 


PROMINENCE  OF  EYEBALLS.  373 

it,  and  to  assure  our  clients  that  it  is  not  of  a  nature  in  itself 
fatal  to  either  life  or  sight. 


{Clinical,  St.  Marys,  May  30,  1863.) 

Elizabeth  M.,  aged  sixteen,  about  whom  I  have  been  lecturing 
as  having  pneumonia  and  typh-fever,  is  worth  observation  also 
on  account  of  the  singular  expression  given  to  her  face  by  eye- 
prominence.  It  seems  she  has  always  been  a  delicate  child,  and 
she  has  had  several  acute  illnesses  of  which  the  last  was  rheu- 
matic fever,  accompanied  by  pain  in  the  heart,  two  years  ago. 
There  are  clear  signs  of  regurgitation  through  the  mitral  valve 
now  heard  by  auscultation,  but  no  other  evidence  of  cardiac 
disease.  She  is  now  flushed  with  the  fever  and  pneumonia,  but- 
is  generally  pale,  and  is  thin  and  weak  looking.  Though  she  is 
of  full  age,  yet  her  mother  says  she  has  not  yet  been  monthly, 
and  her  bust  is  quite  child-like. 

This  unnaturally  protracted  childhood  is  a  frequent  accom- 
paniment of  valvular  disease  of  the  heart ;  so  common  is  the 
association,  that  it  has  not  rarely  been  the  very  phenomenon 
which  has  drawn  my  attention  to  the  heart ;  and  led  to  my  finding 
out  cardiac  lesions  before  unguessed  at.  It  continues  often  till 
after  twenty  years  of  age.  I  take  the  explanation  of  the  facts 
to  be,  that  from  obstruction  or  regurgitation  in  the  central  organ 
blood  enough  is  not  spread  over  the  body  to  carry  out  the  func- 
tional development  fitted  to  the  time  of  life.  Here  you  see  a 
striking  instance  of  it. 

In  marked  contrast  to  the  undeveloped  mammae  is  the  throat 
of  this  girl.  It  has  the  full  round  form,  swelling  out  in  the  mid- 
dle and  sides,  characteristic  of  plump  and  perfect  womanhood. 
On  examination  by  the  hand  this  is  found  due  to  a  soft  enlarge- 
ment of  the  thyroid  gland — an  enlargement  which  I  told  you  in 
my  last  lecture  on  this  point  is  very  commonly  associated  with 
the  eye-prominence  of  which  our  patient  is  the  subject. 

Like  the  last  instance  Ave  had  of  this  disfigurement  it  is  stated 
to   be  worst  when  the  patient  is  ill,  and  indeed  it  has  become 


374  PROMINENCE  OF  EYEBALLS. 

more  remarkable  since  she  has  been  in  the  hospital ;  as  has  also 
the  goitrous  swelling,  which  at  first  was  scarcely  perceptible.  I 
mentioned  to  you  before  the  same  thing  as  occurring  in  the  case 
of  a  surgeon's  daughter,  whose  eye-prominence  is  aggravated  by 
severe  dancing,  long  walks,  and  the  like.  Couple  with  this  the 
fact  that  it  entirely  disappears  after  death,  the  eyes  receding 
completely  into  their  sockets,  and  I  think  you  have  evidence 
enough  that  however  long  and  obstinate  it  is  still  a  temporary 
curable  disease ;  and  moreover,  what  is  of  more  consequence, 
evidence  enough  to  lead  you  to  the  means  of  cure,  namely,  those 
remedies  which  cure  ansemia.  This  swelling  of  the  thyroid  is  of 
a  sort  which  will  be  more  benefitted  by  iron  than  by  iodine. 


LECTURE    XXIX. 
ATROPHY    OF    MUSCLES. 

Part  I. — Cases — Pathology — Treatment — Questions  respecting 
hypertrophy. 

Part  II. —  Case  of  dropped  hand  from  tJie  poison  of  lead — Patho- 
logy of  this  form  of  paralysis  and  its  connection  with  colic — 
Reasons  for  not  considering  its  localization  as  dependent  on  the 
immediate  absorption  of  lead — Treatment  with  iodide  of  potas- 
sium, sulphur  baths,  splints,  electricity,  quinine,  oil,  and  blis- 
ters— which  beneficial,  which  hurtful. 

(Part  l.—ainical,  St.  Marys,  June  13,  1863.) 

Nathaniel  B.,  is  a  thin  ascetic-looking  man,  of  a  faded-leaf 
complexion,  aged  forty-five.  His  expression  recalls  some  stern 
"  Bind-tlieir-kings-in-chains "  of  the  Great  Rebellion,  or  those 
faces  one  sees  in  old  Spanish  monasteries,  not  in  the  flesh,  but 
looking  out  of  the  grim  canvas  of  a  Zurbaran  or  a  Ribrera. 
Nathaniel  B.  is  a  top-sawer  by  trade,  and  Avas  ahvays  a  hearty 
fellow,  able  to  do  a  good  day's  work,  till  ten  months  ago  ;  when 
after  violent  exertion  in  turning  over  a  mass  of  timber,  he  got 
what  he  calls  "a  wrench"  in  the  pit  of  the  stomach,  and  "has 
never  been  the  same  man  since."  The  appetite  failed  and  there- 
with the  strength;  the  muscles  wasted,  and  the  whole  body  grew 
emaciated.  The  loss  of  appetite  then  became  entire,  and  then  in- 
creased to  an  utter  loathing  of  food.  He  went  into  Guy's  Hos- 
pital three  months  ago,  but  left  apparently  dissatisfied  and 
ungrateful.  On  gaining  admission  to  St.  Mary's,  May  22,  he 
seemed  much  cast  down,  expecting  never  to  get  any  better.  He 
was  able  to  walk  about,  and  the  chief  loss  of  power  seemed  in  the 
shoulder-muscles,  the  deltoid  and  biceps ;  and  when  he  tries  to 


376  ATROPHY  OF  MUSCLES. 

"put  np"  the  latter,  tliat  is  to  throw  into  it  the  contractile  ner- 
vous force,  it  feels  quite  soft,  without  any  of  the  corky  elasticity 
which  distinguishes  a  sawer's  arm.  He  is  the  father  of  thir- 
teen children,  but  since  the  commencement  of  his  present  illness, 
he  has  entirely  lost  virile  power.  He  states  himself  to  be  a  per- 
fectly sober  moderate  man,  and  has  a  good  character  on  that 
■score  from  his  employer. 

It  is  scarcely  necessary  to  say  that  the  epigastrium  and  hepatic 
region  were  carefully  examined  for  evidences  of  cancerous  de- 
generation, and  none  was  found.  The  lungs  also  were  well  aus- 
cultated, and  nothing  abnormal  was  detected,  beyond  a  suspicion 
of  slight  comparative  dullness  in  the  right  apex.  He  had  not 
suffered  from  habitual  cough  or  had  any  diarrhoea. 

He  was  at  first  kept  in  bed  and  given  milk  and  beef-tea  every 
two  hours,  with  ten  grains  of  Boudault's  pepsine  powders  three 
times  daily.  In  a  few  days  his  excessive  nausea  and  lowness  of 
spirits  had  abated,  and  he  was  ordered  six  grains  of  quinine  and 
three  drachms  of  cod-liver  oil  daily  in  addition.  In  a  few  days 
more  he  was  tried  Avith  half  a  mutton  chop,  digested  it  well,  and 
on  the  sixth  of  June  was  able  to  take  our  whole  ordinary  diet,  a 
pint  of  milk,  and  a  pint  of  beef-tea,  and  a  pint  of  porter.  On  the 
12th  (yesterday)  he  was  so  much  better,  that  I  thought  it  was 
scarcely  justifiable  to  let  him  occupy  a  place  in  the  hospital  any 
longer,  and  I  trust  he  will  be  able  to  get  on  as  an  out-patient. 

As  he  was  confined  to  his  bed  at  first,  it  was  not  convenient  to 
put  him  in  the  scales,  but  on  May  the  24th  we  found  his  weight 
8  stone  5|  pounds ;  on  the  30th,  8  stone  7|  pounds  ;  on  June  6, 
8  stone  10  pounds ;  on  June  12,  8  stone  lOJ  pounds ;  his  height 
being  5  feet  6  inches. 

The  only  day  on  which  he  did  not  take  the  pepsine  was  May 
29,  when  the  stock  was  accidentally  exhausted.  He  then  com- 
plained of  pain  at  the  epigastrium  and  attributed  that  to  the 
omission  of  the  pepsine. 

This  is  a  specimen  of  disease  not  quite  so  common  as  those  I 
usually  make  the  subject  of  my  clinical  lectures,  and  on  that 
score  not  quite  so  interesting  or  important.  Nevertheless  it  has 
this  importance,  that  if  you  do  not  understand  its  true  nature, 


ATROPHY  OF  MUSCLES.  377 

you  will  be  very  apt  to  treat  badly  the  patients  afflicted,  and  to 
make  them  worse. 

I  have  often  told  you  that  neglect  of  the  powers  our  Creator 
has  dowered  us  with  is  punished  by  their  withdrawal ;  the  intel- 
lectual sluggard  becomes  year  by  year  more  and  more  wanting 
in  memory  and  judgment ;  the  arm  of  the  Hindoo  fakecr,  tied 
upwards  for  a  few  months,  withers  away ;  and  the  calf  of  the 
Chinese  belle  or  of  the  stiff- booted  clodhopper  is  flabby  and 
wasted.  It  is  very  important  that  you  should  know  that  the 
same  penalty  which  is  thus  inflicted  on  willful  underwork,  is  also 
exacted  sometimes  from  overwork,  voluntary  or  involuntary.  If 
a  muscle  is  used  so  as  to  be  worn  out  to  a  degree  beyond  that 
which  the  supply  of  nutriment  is  able  to  repair,  or  if  it  is  so 
continuously  used  that  there  is  no  time  for  repair,  it  becomes  de- 
generated, just  in  the  same  way  as  if  it  had  not  been  used  at  all. 
And  I  am  not  sure  but  what  incautious  intellectual  work  pro- 
duces analogous  results.  How  many  men  do  we  meet  burdened, 
like  little  David  would  have  been  in  Saul's  armor,  with  more 
knowledge  than  they  can  wield  !  Their  minds  seem  day  by  day 
weakened  by  the  stores  they  cannot  use,  so  that  they  become 
less  and  less  able  to  apply  them.  To  how  many  of  our  profes- 
sion does  the  increase  of  practice  bring  the  diminished,  rather 
than  the  increased  results  of  experience,  if  they  do  not  stern^ 
and  conscientiously  reserve  to  themselves  time  for  "the  sessions 
of  sweet  silent  thought." 

But  I  will  confine  iny  observations  now  to  degeneration  of  the 
body,  not  of  the  mind.  We  had  in  the  Cambridge  ward  two 
months  ago  a  blacksmith's  apprentice,  of  slight  frame  and  with 
an  imperfect  aortic  valve,  whose  arms,  especially  the  right,  had 
become  atrophied  from  wielding  too  heavy  a  hammer. 

A  few  years  ago  I  had  in  the  same  ward  a  patient  whose  chief 
employment  was  turning  over  large  rolls  of  lead  ;  and  the  exten- 
sors of  his  right  forearm  had  become  paralyzed. 

About  the  same  time  a  hard-drinking  and  hard-smoking,  but 
hard-working,  cobbler  was  under  my  care,  who  was  unable  to 
raise  the  arms  from  atrophy  of  the  triceps  and  deltoids,  muscles 
absolutely  needed  in  giving  the  artistic  jerk  to  the  thread  which 


378  ATROPHY  OF  MUSCLES. 

these  ivorkmen  affect.  But  his  legs,  which  he  had  rested,  were 
strong  enough. 

The  following  cases,  exhibiting  the  same  agencies  in  action 
under  different  circumstances,  are  from  my  private  note-book. 

E.  C,  aged  fifty,  had  always  been  used  to  the  regular  habits 
proper  for  a  London  lawyer's  wife,  and  not  being  fond  of  needle- 
work, had  generally  amused  her  leisure  with  reading.  At  that 
time  her  eyes  somewhat  failed,  and  she  was  advised  not  to  read 
so  much,  especially  in  the  evening.  As  an  employment  she  sek 
herself  the  task  of  netting.,  first  some  strong-  nets,  and  then  a 
set  of  drawing-room  curtains.  She  worked  several  hours  a  day, 
fastening  the  work  to  her  foot  secundum  artem,  and  drawing 
the  thread  upwards.  After  a  time  she  felt  a  weakness  in  the 
right  shoulder,  then  a  pain  and  stiffness  ;  being  a  very  deter- 
mined kind  of  person  she  tried  to  work  it  off,  rubbed  and  dowsed 
and  shampooed  her  arm  ;  but  the  more  she  did  so,  the  worse  it 
got,  and  she  was  alarmed  at  last  by  the  joint  becoming  exqui- 
sitely painful  to  the  touch.  Then  her  arm  was  put  in  a  sling 
and  tied  up,  she  took  steel  and  wine  and  nutritious  diet  and 
quite  recovered. 

M.,  aged  fifty-four,  has  lived  an  active  literary  life,  writing 
much  and  well.  Her  vigor  of  constitution  is  shown  by  the 
menses  only  lately  beginning  to  grow  scanty  and  irregular.  But 
she  has  a  theory  of  corporeal  discipline  not  reconcilable  with 
rational  physiology;  she  has  thought  to  compensate  for  the  ex- 
haustion of  mental  labor  by  violent  bodily  exertion,  and  has 
been  in  the  habit  of  occupying  her  leisure  by  furiously  digging 
her  garden  with  a  masculine  s])ade,  and  mowing  her  lawns,  not 
with  one  of  the  elegant  new  machines,  but  an  old-fashioned 
scythe.  The  consequence  is  that  her  good  right  hand  has  lost 
its  cunning,  and  a  letter  she  sent  to  seek  my  advice  was  scrawled 
with  the  left.  The  principal  atrophy  is  in  the  deltoid  and  biceps 
muscles  (those  used  in  mowing),  which  are  painful  when  moved, 
but  not  when  pressed.  She  cannot  raise  her  arm  by  independent 
efforts  above  the  level  of  her  waist,  and  it  "feels  out  of  joint  if 
she  tries  to  force  it."  Friction,  brandy  and  salt,  mustard,  &c., 
have  only  made  her  worse.     Her  arm  is  now  by  my  advice  tied 


ATROPHY  OF  MUSCLES.  379 

up,  and  she  is  taking  quinine  and  steel  and  cod-liver  oil  in  small 
doses. 

You  may  easily  recognize  in  all  these  cases  the  same  evil  in 
action  under  corresponding  circumstances — atrophy  produced 
by  local  overwork  of  voluntary  muscle.  And  if  you  think, 
and  examine  closely  the  relations  of  the  muscle  to  the  rest  of 
the  organism,  you  will  see  that  this  overworked  tissue,  is  in  a 
position  not  very  different  from  the  underworked  tissue,  whose 
degeneration  is  so  generally  made  the  subject  of  remark  by 
physiologists.  The  defect  is  in  both  instances  a  want  of  renewal. 
In  underwork  no  demand  is  made  for  a  renewal,  and  in  over- 
work the  demand  is  made,  but  is  not  eflBciently  supplied.  In 
the  one  the  nerve-force,  which  should  guide  and  govern  the 
metamorphosis,  is  let  lie  asleep,  and  in  the  other  has  been  so 
used  up  by  unwonted  toil,  that  it  is  exhausted,  and  for  a  time 
does  not  exist.  So  that  the  last  effect  on  the  muscular  fiber  is 
the  same.  No  new  store  of  muscular  substance  is  laid  in,  and 
the  whole  degenerates  into  inelastic  fiber,  and  finally  into  a  pale 
fatty  tissue  of  still  lower  vitality. 

What  is  called  "over-training"  in  the  prize  ring  has  a  similar 
pathology.  The  power  of  nerve  over  muscular  fiber  is  capable 
of  increase  by  education,  so  that  it  continues  to  brace  it  up 
more  and  more  ;  and  to  make  the  muscles  harder  and  harder 
daily,  till  the  ^'- gladiatoria  totius  corporis  firmitas''  is  attained, 
probably  in  as  great  perfection  in  our  days  as  in  Cicero's.  But 
the  muscular  fibers  themselves  are  not  capable  of  proportionate 
augmentation,  and  when  the  nerves  have  learned  to  exercise 
them  up  to  their  full  force,  are  incapable  of  further  improvement. 
If  then  the  training  is  continued,  the  nerve-force  expends  itself 
in  exciting  the  continuous  functioning  of  the  muscles,  destruc- 
tive assimilation  exceeds  the  constructive;  the  body  "eats  into 
itself  for  lack  of  something  else  to  hew  and  hack,"  and  loses 
weight  beyond  the  mere  loss  of  fat.*     Nerve-force  is  capable,  as 

*  A  moderate  allowance  of  alcohol  during  training,  by  acting  as  an  an;esthetic 
to  the  nervous  system,  tends  to  prevent  this  result.  Modern  trainers  are  apt  to 
enforce  too  great  abstinence,  with  immediate  selfish  advantage  probably,  but  to 
the  final  injury  of  their  pupils. 


330  ATROPHY  OF  MUSCLES. 

far  as  we  know,  of  indefinite  improvement ;  but  the  instrument 
it  plays  upon  cannot  be  made  stronger  than  it  was  originally 
intended  to  be,  and  Avhen  it  is  overstrained  it  degenerates. 
Hence  premature  decay  is  not  rare  among  pugilists,  boat-racers, 
runners,  &c.,  whose  ambition  is  greater  than  their  powers,  and 
those  who  live  by  extraordinary  exertions  of  physical  strength 
have  a  short  average  of  life. 

The  pathology  is  the  same  of  that  impotence  of  the  generative 
and  muscular  functions  which  sometimes  follows  an  active  life 
in  a  tropical  climate,  and  which  cuts  short  the  useful  career  of 
many  of  our  countrymen  in  the  East,  and  which  is  often  unjustly 
attributed  to  lechery  and  drunkenness. 

But  the  most  common  examples  of  the  disease  are  where  it 
occurs  in  one  set  of  muscles  from  special  and  partial  over  use, 
such  as  we  see  in  turners,  carvers  of  ivory  and  hard  woods,  and 
similar  handicraftsmen. 

Muscles  affected  with  atrophy  are  in  an  unnaturally  soft  and 
friable  condition ;  they  are  pale  colored,  and  look  as  if  they  had 
been  macerated  in  warm  water.  They  become  like  the  muscles 
of  a  very  aged  person,  and  in  fact  the  change  is  not  much  differ- 
ent from  a  premature  local  old  age. 

The  change  is  usually  first  discovered  by  the  patient  in  a  much 
more  sudden  manner  than  you  would  have  expected  from  its  pa- 
thology. The  ''wrench"  which  our  sawer  felt  in  his  waist  was 
not  the  real  beginning  of  his  ailment,  but  the  last  straw  which 
broke  the  horse's  back.  And  often  painters  will  tell  you  that 
they  went  on  earning  full  wages  till  a  certain  day,  when  they 
became  utterly  unable  to  raise  their  hand. 

Pain  is  a  variable  symptom.  When  one  or  a  few  muscles 
only  are  affected,  it  is  a  pretty  constant  accompaniment,  and  is 
usually  set  down  as  rheumatism,  or  as  stiffness,  the  result  of 
cold.  In  our  present  patient,  where  many  muscles  were  more 
or  less  acted  upon,  it  was  absent,  or  so  generally  diffused  as  to 
produce  rather  a  feeling  of  mental  depression  and  malaise  than 
of  local  distress. 

Muscular  atrophy  and  local  paralysis  will  sometimes  follow 
chronic  poisoning  by  malaria.     I  have  a  strong  impression  that 


ATROPHY  OF  MUSCLES.  381 

those  are  riglit  who  locate  in  the  nerves  the  chief  injury  inflicted 
by  such  agencies  as  cause  ague  and  its  allied  disorders  of  inter- 
mittent type.  I  am  not  therefore  surprised  at  finding  loss  of 
nervous  function,  either  in  the  form  of  neuralgia  or  paralysis, 
which  can  be  attributed  only  to  the  poison  above  named.  The 
only  thing  which  distinguishes  the  paralysis  from  the  other  forms 
of  aguish  disorder,  and  consequently  obscures  the  diagnosis,  is 
that  it  is  not  intermittent. 

The  treatment  follows  as  a  matter  of  course  from  the  pathology. 
It  consists,  in  the  first  place,  in  enforcing  complete  rest  on  the 
diseased  parts,  in  not  allowing  them  to  have  even  the  labor  of 
supporting  the  members  they  belong  to.  The  dropped  hand  we 
fasten  on  a  splint;  the  paralyzed  humerus  we  put  in  a  sling, 
taking  care  that  the  elbow  is  well  supported  and  does  not  drag 
upon  the  shoulder ;  this  patient,  who  is  the  text  of  my  lecture, 
we  put  to  bed  and  kept  him  there  a  few  days.  Then  we  admin- 
istered animal  food  in  a  form  by  which  the  patient  takes  as  much 
as  the  stomach  can  possibly  digest.  In  this  instance  there  was 
utter  anorexia;  so  beef-tea  and  milk  were  swallowed  in  medicinal 
form  every  two  hours.  To  aid  in  digesting  it  pepsine  was  ordered 
three  times  a  day.  To  supply  a  basis  for  molecular  growth,  cod- 
liver  oil  was  given,  as  soon  as  the  nausea  was  beginning  to  abate. 
And  quinine  was  added  to  brace  the  mucous  membrane  up  to  its 
duty  of  absorption.  I  have  not  prescribed  iron,  but  it  would  be 
quite  rational  to  do  so  now  that  the  intestines  have  begun  to  re- 
cover tone. 

Where  the  pains  are  severe,  cold  douche  baths  and  cold  water 
compresses  give  more  relief  than  anything  else.  Warmth  and 
stimulating  embrocations  seem  to  do  harm. 

Where  malaria  has  been  to  blame,  you  must  be  careful  in  de- 
siring your  patients  to  avoid  the  dew-times — "when  the  mists 
arise  that  have  strength  to  kill."  A  Roman  proverb  warns  the 
native  against  the  hour  before  and  the  hour  after  both  sunset 
and  sunrise,  and  many  a  stranger  has  suffered  in  that  climate 
from  a  neglect  of  popular  experience.  In  England  the  healthy 
population  is  not  debarred  from  the  sweet  influences  of  these 
romantic  hours,  but  those  who  have  once  suffered  from  malaria 
25 


382  ATROPHY  OF  MUSCLES. 

must  remember  that  they  are  more  than  ordinarily  liable  to  a 
fresh  reception  of  the  poison. 

You  may  be  tempted  to  inquire,  if  over-use  of  voluntary  muscle 
causes  atrophy,  and  under-use  also,  while  moderate  use  leaves 
our  frames  well-proportioned,  what  sort  of  use  it  is  which  induces 
hypertrophy  ?  I  confess  that  in  spite  of  the  decies  rejjetita  state- 
ments of  physiologists,  Avho  have  been  copying  one  another  from 
the  time  of  Galen,  I  do  not  know  that  any  kind  of  use  at  all 
does  so,  in  the  sense  of  making  the  substance  of  the  muscle  larger 
when  measured  in  a  state  of  rest.  Doubtless  an  actively  em- 
ployed biceps  or  gastrocnemius  will  more  readily  be  acted  upon 
by  the  voluntary  nerves,  will  contract  more  strongly,  and  be 
harder  and  more  prominent  when  contracted;  but  I  cannot  find 
that  it  grows  at  all  bigger.  I  do  not  absolutely  deny  the  exist- 
ence of  the  physiological  hypertrophy  of  muscle ;  I  only  say  that 
at  all  events  it  is  very  rare,  for  I  cannot  find  any  instance  of  it. 

The  most  notable  example  of  muscular  hypertrophy  ought  to 
be  an  active,  well-made,  one-legged  or  lame  man;  seeing  he  uses 
one  leg  instead  of  two,  it  ought  surely  to  be  enlarged.  Yet  in 
measurino;  in  several  instances  the  remainino-  \cs  in  a  state  of 
rest,  1  cannot  find  that  the  proportion  which  it  bears  to  the  arms 
is  at  all  diiferent  from  the  proportion  in  ordinary  persons  of  the 
same  build.  And  I  cannot  find  that  as  a  rule  blacksmiths'  arms 
are  out  of  proportion  to  their  legs.  Both  are  muscular,  for  none 
but  a  muscular  man  can  work  at  such  a  trade,  and  when  excited, 
the  brachial  muscles  contract  firmer  than  those  of  the  lower  ex- 
tremity, and  are  more  marked;  but  they  are  not  disproportion- 
ately large  when  relaxed. 

Of  course  you  will  find  employed  in  occupations  where  excel- 
lence may  be  attained  by  the  special  exercise  of  one  set  of  mus- 
cles, men  who  have  those  parts  well  developed;  but  they  are  so 
developed  originally,  and  not  by  the  trade.  Big-armed  men 
become  pugilists,  big-legged  men  acrobats;  but  they  do  not 
become  big-armed  or  big-legged  because  they  are  pugilists  and 
acrobats. 

Sometimes  the  development  is  strangely  out  of  accord  with 
the  occupation;  the  wrong  man  gets  into  the  wrong  place.     I 


ATROPHY  OF  MUSCLES.  383 

give  you  the  measurements  of  the  upper  extremities  of  Cordon- 
nier,  an  horticulturist  at  Lisle,  who  has  a  most  extraordinary 
development  of  the  muscular  and  bony  structure.  He  is  not  fat, 
but  hard  and  firm,  weighing  in  his  clothes  but  sixteen  stone,  yet 
the  circumference 

of  the  neck     ....     is  18  inches. 

of  the  breast  ....     is  44J  inches. 

of  the  forearm     .     .     .     is  13  inches. 

of  the  wrist    ....     is  8J  inches. 

of  the  palm  of  hand     .     is  11^  inches. 

How  were  these  Herculean  thews  bred  ?    In  strangling  dragons, 

stunning  wild  bulls,  cleansing  Augean  stables  ?    Did  their  owner — 

"Tear  the  lion  as  the  lion  tears  the  kid, 
Run  on  embattled  armies  clad  in  iron, 
And  weaponless  himself 
Make  arms  ridiculous?'' 

No — they  are  employed  in  tying  up  ladies'  bouquets,  for  his 
skill  in  which  accomplishment  Cordonnier  is  famed.  I  have 
never  heard  of  an  hypertrophy  like  that  being  due  to  over-use. 
Where  the  hypertrophy  exists  in  voluntary  muscles,  I  suspect  it 
is  due  to  a  cogenital  peculiarity,  and  not  to  occupation. 

(Part  II.— Clinical,  St.  3Iarys,  October  31,  1863.) 

In  Benjamin  Franklin  you  have  an  example  of  a  disease  you 
will  very  often  have  to  treat,  if  your  practice  lies  among  artisans, 
the  "dropped  hand"  of  painters  and  glaziers.  He  has  been 
employed  in  the  carriage  building  department  of  the  Great 
Western  Railway,  and  is  an  old-looking  man,  though  only  forty- 
five.  He  has  been  a  spirit  drinker,  but  never  gets  actually 
drunk.  He  has  had  gout  ofi"  and  on  for  the  last  ten  winters, 
and  used  to  take  a  great  deal  of  colchicum.  He  found  however 
that  vegetable  to  produce  symptoms  resembling  those  of  delirium 
tremens,  and  has  given  up  the  use  of  it  in  favor  of  iodide  of  po- 
tassium, which  agrees  with  him  well.*     On  September  28  he 

*  His  plan  is  this — when  the  gout  comes  on,  he  buys  four  pennyworth,  or  a 
drachm,  of  iodide  of  potassium,  dissolves  it  in  a  pint  of  water,  and  takes  it  in 
the  twenty-four  hours. 


384  ATROPHY  OF  MUSCLES. 

gave  us  the  following  history.  He  had  heen  first  taken  ill  three 
Aveeks  previously  with  crampy  pains  in  the  belly,  •which  got 
worse  in  spite  of  castor-oil,  till  the  28th.  About  the  same  time 
his  hands  began  to  droop,  and  when  we  took  him  in  hand,  at 
that  date,  he  could  not  raise  them  on  the  wrist  at  all.  There 
were  also  severe  pains  in  the  calves  and  thighs.  The  gums  had 
a  livid  line,  characteristic  of  saturnine  poisoning,  to  the  breadth 
of  an  eighth  of  an  inch  round  the  teeth,  and  the  description  he 
gives  of  his  employment  shows  that  he  is  much  exposed  to  the 
influence  of  white  lead.  Besides  using  white  lead  to  form  what 
is  technically  called  the  "body"  of  the  color  laid  on,  he  has  also 
employed  mercurial  colors  in  the  fine  work  required.  And  this 
addition  of  mercurial  to  saturnine  poisoning,  or  perhaps  his  bad 
habit  of  spirit-drinking,  caused  a  little  peculiarity  in  the  case, 
which  was  observed  on  his  first  admission:  his  arms  were  noticed 
to  tremble  when  he  held  them  out,  as  if  afilicted  with  paralysis 
agitans.  This  peculiarity  soon  passed  away,  and  there  is  nothing 
else  to  take  the  case  out  of  the  category  of  typical  and  ordinary 
instances  of  disease,  such  as  I  endeavor  to  select  for  my  clinical 
illustrations. 

I  am  disposed  to  explain  a  great  part  of  the  pathology  of 
painter's  dropped  hand  on  the  same  principle  which  I  stated  to 
you  on  a  former  occasion  apropos  of  simple  muscular  atrophy. 

The  white  lead  is  slowly  absorbed  by  its  gradual  and  sparing 
solution  in  the  fluids  of  the  body,  which  are  rendered  capable  of 
dissolving  it  by  their  saturation  with  carbonic  acid.  In  the  blood 
it  destroys  the  red  globules,  and  carried  to  the  muscles,  removes 
their  red  color  also,  and  renders  them  incapable  of  contracting 
except  under  extraordinary  nervous  influence.  This  paralyzing 
effect  is  most  commonly  shown  on  the  involuntary  fibers  of  the 
intestines,  producing  the  well-known  painter's  colic.  There  are 
two  reasons  why  it  should  be  exhibited  soonest  on  these  intesti- 
nal fibers;  first,  they  are  the  nearest  to  the  usual  portal  by 
which  the  poison  enters  the  path  of  the  food ;  secondly,  they  are 
weak  muscles,  and  yet  have  constant,  almost  unintermitting  work 
to  do  so,  so  that  they  can  have  but  little  repose  during  which 
recovery  from  exhaustion  might  be  possible.     Hence  colic  and 


ATROPHY  OF  MUSCLES.  385 

constipation  from  arrested  vitality  in  the  intestines  is  the  com- 
monest result  of  lead  poisoning. 

The  same  principles  apply  to  the  muscles  of  voluntary  motion 
in  the  trunk  and  limbs,  and  most  especially  in  the  latter.  Those 
muscles  become  most  paralytic  which  are  most  exhausted  by  the 
peculiar  employment  of  the  individual.  I  had  a  patient  a  few 
years  ago  whose  work  lay  in  a  sheet-lead  warehouse,  and  con- 
sisted of  moving  very  heavy  masses  of  that  weighty  metal.  He 
became  gradually  paralytic  in  the  right  forearm,  and  weak  in  the 
loins,  parts  extraordinarily  exhausted  by  his  labor.  Painters, 
especially  fine  painters,  such  as  those  employed  upon  carriages, 
do  not  use  the  biceps,  or  the  shoulder,  or  the  dorsal  muscles  more 
than  other  people  ;  but  they  do  use  excessively  the  extensors  of 
the  hand.  Try  for  yourselves  the  drawing  of  fine  lines  on  a  wall 
with  the  arm  free,  and  you  will  find  how  painfully  tired  the  out- 
side of  the  forearm  soon  gets.  Artists  usually  rest  the  wrist  on 
a  mahlstick,  with  the  result  of  saving  these  muscles,  and  artists 
seldom  get  paralysis.  But  for  some  reason  or  other  artisans 
generally  adopt  another  plan  of  gaining  the  requisite  fulcrum 
for  steadying  the  line ;  they  fix  the  hand  by  means  of  the  fourth 
and  little  finger  on  the  plain  surface,  calling  the  support  thus 
obtained  their  "  compass,"  and  then  wield  the  brush  with  the 
thumb  and  forefinger.  This  throws  a  terrible  strain  on  the  ex- 
tensors of  the  wrist,  and  they  suffer  accordingly.  The  over 
exhausted  fibers  become  atrophied,  pale,  and  paralytic ;  while 
other  muscles  escape,  although  equally  exposed  to  the  baneful 
influence  of  the  lead,  but  not  so  much  used. 

I  am  not  certain  whether  the  neighborhood  to  the  paint  has 
much  to  do  with  the  hand  becoming  paralytic.  At  first  sight 
one  would  be  disposed  to  think  it  had.  But  then  on  reflection 
you  will  observe  that  other  muscles  which  are  equally  near,  such 
as  the  flexors,  do  not  become  aftected  ;  and  others  which  are 
still  nearer  also  escape.  A  dropped  hand  can  often  twiddle  its 
fingers  with  their  interossei  and  lumbricales,  bend  in  its  tluimb 
with  its  adductor  pollicis,  and  even  exhibit  the  delicate  action  of 
the  palmaris  brevis.  Now,  the  fibers  of  these  muscles  have  but 
a  layer  of  skin  and  dirt  between  them  and  the  paint  during  the 


386  ATROPHY  OF  MUSCLES. 

whole  of  working  hours,  whereas  the  forearm  is  scarcely  even 
directly  exposed  to  it ;  for  it  is  very  unusual  to  see  fine  painters 
tuck  up  their  shirt  sleeves,  and  the  majority  even  work  in  their 
fustian  jackets ;  yet  it  is  the  forearm  that  becomes  affected,  and 
not  the  more  directly  exposed  muscles. 

A  very  similar  kind  of  palsy  is  apt  sometimes  to  effect  clerks 
and  others  engaged  in  writing,  who  wield  their  pens  in  a  stiff 
way  without  properly  resting  their  elbows ;  it  may  be  called 
paralysis  scriptorum. 

The  man  who  is  the  text  of  the  present  lecture,  was  treated 
with  iodide  of  potassium,  to  bring  the  lead  remaining  in  him 
into  a  soluble  form  capable  of  being  removed  by  the  fluid  excre- 
tions. He  had  also  hydro-sulphurous  baths  thrice  a  week  to  test 
the  progress  of  this  removal  of  the  poison.  For  ten  days  the 
secretion  of  his  skin  in  the  delicate  places  (such  as  the  axilla) 
was  stained  blackish  with  each  bath  from  the  sulphuret  of  lead 
formed.  But  after  ten  days  the  stain  was  no  longer  visible  ;  and 
at  the  same  time  the  livid  line  round  the  gums  began  to  vanish. 
He  was  losing  his  lead — the  cause  of  the  disease  was  being 
removed. 

Yet  though  the  cause  was  being  removed,  the  disease  remained, 
and  indeed  still  remains  to  a  considerable  extent.  The  treat- 
ment applied  to  it  has  been  first — Rest ;  the  hands  are  placed 
on  splints  for  the  greater  part  of  the  day  and  night,  so  that  their 
weight  may  not  drag  upon  the  muscles.  Secondly — Intermittent 
motion ;  electric  shocks  are  passed  through  the  muscles  for  a 
short  time  daily.  Thus  the  atrophy  of  over-exertion  and  the 
atrophy  of  disease  are  both  guarded  against  by  imitating  the 
most  healthy  natural  circumstances  of  rest  and  motion. 

He  is  also  taking  quinine  and  cod-liver  oil,  to  furnish  a  basis 
of  molecular  growth  for  renewed  muscvilar  fiber ;  and  Avith  this 
he  has  decidedly  improved  in  general  health,  and  is  able  to  raise 
the  wrists  much  better. 

While  I  tell  you  what  has  benefited  him,  I  should  also  call 
your  attention  to  one  thing  which  in  both  his  own  and  my 
opinion  has  done  harm.  As  an  experiment  I  treated  the  fore- 
arms for  three  days  with   small  flying  blisters,  never  allowing 


ATROPHY  OF  MUSCLES.  387 

them  actually  to  produce  vesication,  but  to  be  moved  onwards 
when  the  skin  became  reddened.  The  paralysis  was  certainly 
worse  during  this  application,  and  for  several  days  afterwards ; 
so  of  course  I  shall  not  repeat  it.  What  I  have  previously 
described  in  this  lecture  to  you  constitutes  the  ordinary  and 
typical  treatment  of  dropped  hand ;  and,  though  I  mention  it  as 
part  of  the  established  medication  in  my  systematic  lectures,  I 
have  always  felt  doubtful  in  what  sort  of  cases  blistering  is  bene- 
ficial, if  any ;  for  I  have  never  been  able  in  my  own  experience 
to  assign  any  good  influence  to  it  independent  of  other  treatment. 


LECTURE   XXX. 
CHOREA. 

Part  I. — Case  treated  without  medicine — This  case  a  recent  one 
— Principle  of  treatment. 

Part  II. — Four  long-continued  hut  curable  cases  treated  with 
arsenic — Quoted  as  specimens  of  the  disease  as  usually  seen 
— Effect  of  forcible  control  over  the  movements. 

Part  III. —  Records  of  three  fatal  cases  and  two  unaffected  by 
treatment — Connection  of  chorea  and  rheumatism  and  dis- 
ease of  heart  statistically  deduced  from  the  records  of  thirty- 
three  cases. 

(Part  I. — Clinical,  St.  Marys,  February  20,  1863.) 

A  LAD  of  nine  years  old,  Henry  G.,  was  taken  in  on  the  19th 
of  last  month  for  chorea.  His  parents  stated  that  the  attack 
had  come  on  suddenly  a  week  previously  without  any  assignable 
cause,  and  while  he  was  sitting  at  dinner.  It  began  by  convul- 
sive movements  of  the  arms  and  facial  muscles,  and  very  soon 
the  whole  body  became  affected.  As  he  lay  in  bed  I  think  I 
never  saw  more  violent  and  uncontrollable  motions  of  the  limbs 
and  body.  He  was  never  still,  but  speaking  to  him  or  touching 
the  bed  excited  convulsions  in  the  same  electric  manner  as  in 
hydrophobia,  and  judging  by  his  wailing  they  seemed  to  be  very 
painful.  He  was  unable  to  retain  his  foeces  or  his  urine.  He 
was  stated  to  have  been  subject  to  worms,  as  is  the  case  with  half 
the  children  of  our  laboring  classes ;  so  I  gave  him  once  and 
again  a  stout  jalap,  aloes,  and  calomel  purge  to  ascertain  the  fact; 
but  no  worms  or  mucus  appeared,  nor  had  there  been  any  col- 
lection of  old  foeces  in  the  colon.  Beyond  that  he  has  had  no 
medicine,  except  on  one  occasion  a  little  catechu  to  solidify  the 


CHOREA,  389 

stools,  which  were  passed  involuntary,  and  prevent  them  dirty- 
ing the  sheets  so  much.  Yet  you  have  seen  the  disease  pass 
away  entirely,  so  that  on  the  llth  instant  the  case-book  records 
that  he  carried  the  inkstand  steadily  round  the  ward  for  us, 
handing  it  with  one  hand,  and  he  has  been  making  himself  use- 
ful to  the  ward-sister  by  serving  out  patient's  dinners.  I  have 
kept  him  in  the  hospital  till  to-day,  solely  to  see  if  any  relapse 
would  occur. 

I  said  he  had  no  medicine,  but  I  did  not  say  he  had  no  treat- 
ment. He  was  surrounded  as  he  lay  in  bed  with  toys,  and  he 
was  induced  to  make  every  eiFort  to  retain  them  in  his  hands. 
In  two  days  he  began  to  get  quieter,  but  not  much  more  advance 
was  made,  till  his  regaining  some  power  over  the  sphincters 
enabled  us  to  have  him  dressed  and  to  set  him  to  walk  in 
measured  step  about  the  ward.  Then  we  imperilled  our  crock- 
ery in  a  good  cause  by  letting  him  carry  it  about  and  clean  it, 
till  he  rapidly  acquired  the  steadiness  you  saw  him  exhibit  a 
week  ago. 

The  object  aimed  at  was  to  draw  off  his  attention  from  his 
miserable  state,  to  concentrate  the  mental  forces  in  the  endeavor 
to  acquire  power  over  voluntary  muscle,  and  thus  to  renew  their 
lost  control. 

This  is  obviously  not  a  disease  which  must  necessarily  go  on 
from  bad  to  worse  if  unarrested  by  art.  The  long  list  of  varied 
remedial  agents  employed,  many  of  them  repugnant  to  one 
another,  is  enough  to  make  us  suspect  this.  Dr.  Reeves,  in  his 
statistics  of  eighty-four  cases  occurring  in  the  Norwich  hospital, 
states  that  the  shortest  duration  of  the  disease  under  pharma- 
ceutical treatment  was  two  weeks  ;  the  longest  eight  months  ; 
and  the  common  average  seven  weeks.*  I  suspect,  though  I 
have  no  statistics  to  show  it,  that  the  common  average  of  dura- 
tion of  recent  cases  where  no  medicines  are  taken,  would  be  very 
similar. 

The  pathology,  or  explanation  of  the  immediate  internal  cause 
of  chorea,  is  quite  unknown.  Sydenham  ascribes  it  to  a  "hu- 
mor thrown  upon  the  nerves."     Yet  in  three  fatal  cases  I  have 

*  "Edinburgh  Med.  and  Surgical  Journal,"  vol.  viii,  p.  314. 


390  CHOREA. 

found  the  nervous  system  perfectly  healthy,  in  a  fourth  there 
were  tubercles  in  the  spinal  cord.  Dr.  Cullen  thought  that  the 
malady  depended  on  "a  state  of  mobility"  of  the  system ;  that 
is  to  say,  that  the  limbs  move  about  too  much  because  they  are 
too  movable.  Dr.  Marshall  Hall  attributed  it  to  "  reflex  action ;" 
but  talking  of  "reflex  action"  is  merely  to  class  the  phenomena 
of  convulsions  under  a  common  name,  for  nobody  has  yet  dis- 
sected out  the  "reflex"  nerves.  So  I  do  not  think  the  learned 
have  contributed  much  to  our  knowledge  of  the  subject. 

You  may  observe  that  in  chorea  the  principal  muscle  in  any 
intended  motion  is  pretty  fairly  obedient  to  the  will ;  this  lad, 
when  he  was  bidden  to  put  out  his  arm,  put  it  out ;  but  those 
muscles  whose  motions  are  normally  associated  with  the  princi- 
pal one,  did  not  act ;  he  did  not  put  it  out  straight,  and  twisted 
it  in  every  direction  but  the  correct  one.  Hence  Darwin  shrewdly 
classes  it  among  "  diseases  (defects)  of  association,"  that  is  to 
say,  cases  where  the  necessary  connection  between  certain  vital 
acts  is  overthrown. 

The  existing  or  external  causes  are  sometimes  easier  to  dis- 
cover. You  have  cases  where  the  patient  is  anaemic,  is  teething, 
has  mucous  intestines  and  disordered  alvine  secretions  impeding 
digestion,  skin  eruptions,  retarded  catamenia,  pregnancy,  dis- 
eased bladder  or  uterus,  perineal  fistulse,  tubercles  in  spinal 
cord.  (In  these  three  latter  cases  I  am  recalling  to  my  mind 
examples  of  fatal  termination.)  Many  other  patients  again  at- 
tribute the  disease  to  fright.  In  such  instances  you  find  that 
the  disease  obstinately  remains  till  the  exciting  cause  is  removed, 
and  then  begins  gradually  to  decline.  Under  such  circumstances 
the  plan  of  treatment  is  obvious  enough ;  you  must  turn  your 
efforts  to  the  exciting  cause,  if  it  is  removable,  and  then  expect 
with  confidence  that  the  chorea  will  disappear  in  about  a  fort- 
night. If  the  exciting  cause  is  permanent,  or  if  (as  is  the  case 
of  pregnancy)  it  is  too  valuable  to  be  got  rid  of,  I  cannot  find 
that  the  specifics  do  any  good. 

But  in  a  very  large  number  of  cases  you  can  discover  no  ex- 
citing cause.  Perhaps  it  has  passed  away  ;  perhaps  even  if  you 
had  watched  the  patient  all  along,  you  would  not  have  discovered 


CHOREA.  391 

it  on  account  of  its  secret  nature.  In  such  cases  I  have  usually 
been  in  the  habit  of  administering  arsenic  ;  but  really  I  cannot 
say  that  any  patients  under  arsenic  have  ever  passed  from  a 
severe  state  to  one  of  complete  voluntary  control  more  quickly 
than  this  boy  without  arsenic. 

You  may  say  truly  that  chorea  exhibits  sometimes  a  tendency 
to  become  chronic  in  cases  where  the  general  health  only  has 
been  attended  to.  But  I  do  not  think  that  proves  anything 
against  my  idea  of  its  nature  being  to  get  well  of  its  own  accord. 
I  believe  that  in  these  protracted  cases  there  is  a  continual 
renewal  of  the  cause  of  the  disease  ;  that  it  is  in  fact  kept  up  by 
injudicious  management.  One  of  the  most  common  forms  of 
injudicious  management  is  the  fixing  of  the  patient's  attention 
upon  the  deficiency  of  voluntary  control.  They  are  told,  and 
wondering  bystanders  are  told,  often  with  exaggeration,  how  bad 
they  are  ;  the  malady  is  painted  in  heightened  colors ;  pitying 
friends  off"er  unnecessary  help  ;  cruel  companions  ridicule  their 
infirmities ;  till,  like  the  subjects  of  electro-biology,  or  mesmer- 
ism, they  lose  control  more  and  more  from  being  told  that  it  is 
lost.  You  may  see  this  mental  cause  of  the  aggravation  of  the 
disease  most  clearly  shown  if  two  or  three  patients  chance  to 
be  put  together  in  the  same  ward.  It  is  impossible  to  avoid  it 
sometimes,  but  you  will  observe  that  they  always  make  one 
another  worse,  especially  if  females.  If  one  is  getting  better, 
she  will  be  immediately  thrown  back  again  by  the  introduction 
of  a  new  companion  similarly  affected  ;  and  not  rarely  a  patient 
previously  free  will  catch  it  by  the  contagion  of  the  eyes. 

The  influence  for  you  to  exercise  for  the  cure  is  the  very 
reverse  of  that  which  makes  the  disease  worse ;  you  must  en- 
courage the  patients  to  make  every  exertion  to  direct  the  move- 
ments of  the  limbs  and  let  them  perceive  as  little  as  possible 
their  deficiencies  in  this  respect.  Above  all,  let  them  avoid 
looking-glasses  or  the  depressing  sight  of  other  unfortunates  in 
the  same  condition.  Poor  persons  are  best  treated  as  in-pa- 
tients of  a  hospital,  for  the  advantage  of  getting  them  away 
from  their  injudicious  friends  outweighs  the  risk  of  possibly 
coming  in  contact  v.ith  other  choreics.     If  the  patients  are  not 


392  CHOREA. 

in  a  position  of  life  to  make  this  resource  available,  at  all  events 
get  them  away  from  home  as  soon  as  possible.  Sent  under  the 
care  of  a  judicious  governess  to  the  seaside,  or  anywhere  else 
for  an  excuse,  many  children  recover  rapidly  who  at  home  would 
have  gone  on  relapsing  and  relapsing  again  every  week. 

Slow  walking  in  timed  step  is  excellent  practice  for  regaining 
directing  power,  and  I  dare  say  slow  music  and  solemn  minuets 
would  be  equally  efficacious;  you  may  remember  that  the  Taran- 
tella was  so  called  from  beino-  used  to  relieve  a  nervous  affection 
falsely  attributed  to  a  poisonous  spider  ;*  carrying  trays  and 
crockery,  and  other  things  that  demand  care,  assists  the  cure. 
In  short,  using  the  will  contributes  more  than  anything  else  to 
its  renewal,  and  is  the  only  real  "specific"  for  chorea,  when 
once  the  original  exciting  cause  has  been  removed. 


(Part  IL— Clinical,  St.  Marys,  May  30,  1863.) 

Maria  S.,  aged  thirteen,  was  received  May  1,  with  very  severe 
chorea  of  six  weeks'  duration.  No  cause  could  be  assigned  by 
her  mother,  nor  could  any  worms  be  found  in  the  fieces,  but 
from  her  dirty  and  neglected  appearance  and  the  unnatural 
smell  and  color  of  the  alvine  excretion,  I  have  no  doubt  she  has 
been  fed  on  diet  very  unsuitable  to  a  growing  girl.  The  muscu- 
lar movements  were  so  excessive  as  entirely  to  prevent  her 
speaking  intelligibly,  but  she  was  quite  quiet  when  asleep.  She 
is  a  thin  but  healthy  looking  child,  and  the  only  abnormal  phe- 
nomenon is  the  fetidity  of  the  stools.  She  was  kept  for  six 
days  without  medicine  in  order  to  observe  the  case,  and  no  im- 
provement was  found  from  the  better  food  and  discipline  of  the 
hospital.  She  was  then  put  upon  four  minims  thrice  a  day  of 
liquor  potassse  arsenitis,  and  immediately  began  to  get  better. 

*  la  Kircher's  specimens  of  Tarantella  tunes  the  first  are  merry  jigs,  but  the 
last  is  like  a  funeral  march,  and  must  have  been  composed,  as  one  would  guess, 
for  some  church  dignitary  affected  with  the  curious  contagious  chorea  of  the 
fifteenth  century.  See  Hecker's  "  Epidemics  of  the  Middle  Ages." — Dancing 
Mania,  p.  172. 


CHOREA.  393 

On  the  9th  she  could  walk  up  and  down  the  ward  and  feed  her- 
self, and  is  now  able  to  assist  in  washing  up  the  crockerj,  and 
will  leave  the  hospital  shortly. 

Along  with  the  last  patient  I  also  took  in  Richard  B.,  aged 
nineteen,  a  chairmaker.  Three  months  previously  he  had  been 
obliged  to  walk  home  four  miles  in  the  dark,  of  which  he  had 
from  childhood  been  much  afraid.  He  was  overwhelmed  with 
fright,  but  concealed  his  fears  out  of  shame.  After  this  he  be- 
came very  nervous,  and  chorea  gradually  supervened.  The  in- 
voluntary movements  increased  so  much,  that  for  six  weeks  he 
had  been  unable  to  work  at  his  trade.  He  is  very  thin  and  pale, 
with  blue  cornea  to  his  eyes.  He  was  put  upon  misturse  ferri 
.^j  ter  die,  to  which  has  been  added  since  5j  of  cod  oil.  And 
he  has  also  now  a  shower-bath  every  morning.  On  the  9th  he 
was  steadier  than  on  admission,  but  then  the  improvement  be- 
came stationary,  so  that  I  resolved  to  treat  him  also  with  arsenic. 
The  quantity  has  been  gradually  increased  up  to  TT|xvi  of  the 
liquor  potassse  arsenitis  three  times  a  day,  and  he  has  been 
slowly  but  steadily  improving. 

A  third  patient,  Emma  B.,  aged  fifteen,  has  been  under  my 
care  only  eight  days.  The  catamenia  had  occurred  for  the  first 
time  two  months  previously,  and  about  the  period  when  they 
ought  to  have  been  again  present  she  was  observed  to  get  rest- 
less and  fidgety.  In  a  fortnight's  time  this  restlessness  became 
complete  chorea,  which  was  the  prominent  disease  on  admission. 
The  movements  were  then  almost  entirely  confined  to  the  right 
side  of  the  body.  Two  nights  before  admission  she  went  ofi" 
into  an  hysterical  fit,  but  this  had  not  before  been  observed,  nor 
has  it  since  occurred.  After  she  had  been  in  hospital  a  few 
days  we  found  that  the  chorea  came  on  in  paroxysms  of  about 
two  hours'  duration,  during  which  it  was  very  violent  over  the 
whole  person.  In  the  intervals  she  was  comparatively  quiet, 
and  could  speak  easily,  though  not  extend  the  right  arm 
straight. 

I  ordered  at  first  valerian,  which  seemed  to  do  no  good,  and 
now  she  is  taking  arsenic  like  the  others.  She  has  also  in 
addition  a  warm  hip-bath  nightly. 


394  CHOREA. 

These  are  interesting  cases  for  you  to  watch,  for  they  present 
examples  of  the  disease  when  it  has  already  assumed  a  chronic 
form,  and  when  the  mere  fact  of  its  existence  makes  it  reproduce 
itself,  if  I  may  so  express  myself.  I  mean  that  the  constant 
movement  and  annoyance  still  further  Aveaken  the  already 
weakened  and  predisposed  body,  and  so  instead  of  tending  to 
recovery  naturally  tend  to  a  prjolongation  of  the  malady.  In 
this  stage  it  will  not  get  well  without  some  strong  measures  in 
the  way  of  medicine.  You  saw  that  the  child,  Maria  S.,  got  no 
better  during  the  week  that  she  was  treated  by  diet  and  discipline 
alone ;  so  we  must  have  recourse  to  the  pharmacopoeia. 

One  very  powerful  aid  is  iron,  and  a  great  many  cases  may  be 
cured  with  that  remedy,  either  in  the  form  of  the  red  rust  or  of 
Griffith's  mixture.  But  you  saw  that  iron  was  beneficial  only 
during  the  first  two  or  three  days  to  the  boy  Richard  B.  And 
the  disease  may  come  on  even  while  a  patient  is  taking  iron. 
It  did  so  a  few  years  ago  in  a  boy  in  this  hospital,  for  whom  I 
had  prescribed  that  mineral  for  tubercular  consumption  (No.  in 
Register,  8626,  November  13,  1857).  Nevertheless  he  got  well 
of  it  without  any  change  in  the  treatment.  Perhaps  he  caught 
it  by  imitation  of  some  other  patient  in  the  Avard,  but  the  clerk 
has  made  no  note  of  the  fact.  If  so,  both  the  supervention  of 
the  malady  and  its  cure  are  easiest  explained. 

Valerian  is  sometimes  useful  in  chorea  which  arises  in  girls 
about  and  soon  after  the  time  of  puberty,  when  it  is  apt  to 
assume  a  paroxysmal  form.  This  paroxysmal  form  we  observed 
in  Emma  B.,  but  still  the  valerian  did  not  cure  her. 

In  all  forms,  however,  you  have  seen  a  very  decided  improve- 
ment under  the  use  of  arsenic. 

I  should  not  have  called  upon  you  to  notice  this,  had  they 
been  recent  cases,  or  if  they  had  been  cases  in  Avhich  a  turn 
towards  recovery  had  already  been  taken.  Under  such  circum- 
stances you  may  easily  deceive  yourselves  as  to  the  action  of 
medicines,  which  do  not  cause,  but  are  merely  given  along  with 
the  cure.  About  arsenic,  however,  I  do  not  think  you  can  have 
any  doubt,  observing  these  and  similar  patients,  that  it  really 
acts  as  a  special  tonic  to  the  nervous  system, — curing  the  chorea 


CHOREA.  395 

irrespectively  of  the  cause  whence  it  has  originated.  As  arsenic 
is  not  a  normal  constituent  of  any  part  of  the  body,  and  cannot 
be  imagined  to  replace  any  normal  constituent;  while  at  the 
same  time  patients  increase  in  strength  and  weight  during  the 
course  of  taking  it,  I  suppose  it  must  be  an  indirect  constructive, 
acting  powerfully  on  the  nervous  system. 


(^Clinical,  St.  Marys.,  June  13,  1863.) 

Of  the  three  patients  about  whom  I  lectured  a  fortnight  ago 
Maria  S.  has  gone  home  Avell,  Emma  B.  is  at  work  washing  up 
cups  and  saucers,  and  Richard  B.  has  improved  as  to  his  arms 
and  legs,  being  able  to  walk  straight  and  hold  out  an  inkstand 
for  me  to  write  prescriptions.  But  his  organs  of  speech  have 
not  improved  at  all.  He  stammers,  and  chews,  and  gnashes  his 
teeth  most  painfully,  whenever  he  struggles  to  talk. 

Impediments  to  articulation  are  usually  the  most  difficult  part 
of  the  malady  to  cure.  Many  who  have  had  it  only  in  childhood 
will  stammer  all  their  lives.  So  delicate  are  the  muscular  motions 
required  for  the  rapid  modifications  of  form  which  make  the 
sounds  of  the  different  letters  in  speaking,  and  so  decided  and 
firm  must  they  be  for  intelligible  enunciation,  that  the  slightest 
deficiency  becomes  immediately  apparent.  A  muscular  con- 
traction which  might  be  well  enough  directed  to  guide  the  fingers 
in  writing,  may  be  very  incompetent  to  shape  tongue  and  lips 
in  pronouncing.  A  tremor  not  noticed  in  the  former  is  dis- 
agreeably prominent  in  the  latter. 

The  annoyance  to  the  patient  caused  by  this  difficulty  still 
further  increases  it,  so  that  it  reproduces  itself  and  becomes 
chronic.  More  than  that,  the  glottis  is  irregularly  acted  upon, 
and  closed  when  it  ought  to  be  opened,  so  that  speech,  and 
sometimes  the  breath,  is  absolutely  arrested.  Nobody  stammers 
in  singing,  when  the  glottis  is  kept  open  to  form  the  musical 
tone. 

Stuttering  and  stammering;  are  in  fact  a  local  chorea.  There 
is  a  deficiency  of  voluntary  control  over  the  muscles  of  speech. 


396  CHOREA. 

In  a  recent  case,  such  as  this,  very  likely  the  arsenic  will  be 
of  use,  but  I  do  not  know  whether  it  would  be  available  where 
the  defect  has  become  habitual.  The  best  way  under  that  cir- 
cumstance is  for  the  person  to  humble  himself  to  the  infant  state, 
and  be  taught  to  speak  all  over  again.  He  can  get  instruction 
from  those  ingenious  tutors  who  teach  the  deaf  and  dumb,  and 
systematically  learn  to  shape  slowly  and  deliberately  his  mouth 
into  the  form  requisite  for  enunciating  each  letter  separately. 
By  practising  this  at  his  leisure  and  before  a  looking-glass  he 
may  gain  great  control  over  the  articulating  muscles. 

I  shall  in  this  case  continue  the  arsenic,  and  not  recede  from 
the  large  dose  (HX-'^vi  of  the  liquor  potassse  arsenitis)  unless  there 
is  perceived  some  poisonous  action,  such  as  sore  throat,  inflam- 
mation of  the  eyes,  severe  griping.  I  have  also  directed  him  to 
recite  frequently  in  front  of  a  mirror  sundry  choice  scraps  of 
literature  relating  to  Peter  Piper  and  his  practices,  which  are 
popular  practice  in  p's. 

\_JVote  added  July  3.  This  boy  improved  slowly,  the  arsenic 
having  been  increased  up  to  lT[xviii  of  Fowler's  solution  three 
times  a  day.  He  went  out  cured  and  able  to  go  to  work  to- 
day.] 

I  have  begun  arsenic  with  another  patient  taken  in  yesterday, 
June  12,  Ann  W.,  whose  case  presents  some  analogy  to  the 
present  condition  of  this  boy,  in  that  the  disease  is  limited 
almost  entirely  to  one  part. 

The  said  Ann  W.,  a  fine  tall  girl  of  thirteen  only,  though 
she  looks  older,  has  been  subject  to  occasional  chorea  since  she 
was  five  years  of  age.  Latterly  she  has  had  an  attack  annually, 
and  last  year  two  attacks.  The  jactitation  is  almost  always 
confined,  as  now,  to  one  arm  ;  with  one  exception  to  the  left 
arm.  But  that  once  she  had  it  in  the  right  arm  only,  and  last 
year  in  the  left  leg  and  left  arm  only.  The  catamenia  have  not 
yet  been  established.  There  is  no  abnormal  murmur  in  the 
heart,  and  she  has  never  been  subject  to  rheumatism  in  any 
form.     I  have  ordered  her  arsenic  and  shower  baths. 

It  will  be  interesting  to  watch  this  case  and  see  whether  the 
very  local  affection  is  benefited  by  arsenic  as  decidedly  as  the 
more  general. 


CHOREA.  397 

\_Note  added  July  3.  The  dose  of  liquor  potassge  arsenitis  was 
gradually  increased  to  TTLxiv.  The  patient  was  able  to  wash  up 
crockery  after  she  had  been  in  hospital  ten  days,  and  was  dis- 
charged cured  this  morning.] 

For  three  days  I  tried  the  experiment  of  controlling  the 
spasmodic  movement  by  fastening  the  affected  arm  against  the 
side.  The  effect  was  to  make  it  decidedly  much  worse.  This 
observation  is  quite  in  accordance  with  the  theory  I  hazarded  in 
an  earlier  part  of  this  lecture  that  the  voluntary  nervous  force 
is  deficient  from  want  of  use,  and  that  the  exercise  of  the  direct- 
ing will  is  an  important  element  in  the  cure.  For  that  which 
is  cured  by  the  exercise  of  voluntary  effort  you  would  expect 
to  be  made  worse  by  forcible  involuntary  control,  and  vice 
versd.~\ 


(Part  III. — Continuation  of  the  same  lecture.) 

I  must  not  let  you  suppose  from  the  usually  fortunate  result 
of  treatment,  of  which  you  are  sure  to  see  repeated  examples, 
that  a  favorable  prognosis  can  be  always  given  as  a  matter  of 
course  in  chorea.  It  is  true  that  during  the  time  in  which  you, 
my  present  class,  have  been  pupils,  there  have  been  no  deaths 
among  my  patients  so  affected,  nor  indeed  any  discharged  as 
incurable.  But  in  my  case-books  there  are  several  of  both  sad 
sorts,  and  I  will  briefly  extract  them  to  damp  any  too  cheerful 
ideas  you  might  have  acquired. 

John  D,,  (No.  in  Reg.  442)  aged  sixteen,  was  transferred  to 
me  from  Mr.  Coulson,  February  13,  1852.  He  had  been  operated 
upon  for  stricture  by  the  perineal  section,  and  had  accidentally 
been  placed  in  a  bed  opposite  to  one  occupied  by  a  boy  with  St. 
Vitus'  dance.  He  soon  began  to  imitate  the  movements  of  his 
neighbor,  and  though  removed  to  another  ward  he  got  worse 
and  worse,  and  lost  all  control  over  his  limbs.  When  trans- 
ferred he  was  found  to  have  pericarditis,  but  the  time  of  its 
supervention  had  not  been  noticed.  He  continued  to  get  worse 
and  worse,  abrasions  and  sloughs  and  abscesses  formed  in  various 
26 


398  CHOREA. 

external  parts,  and  he  died  delirious  Feb.  28.     It  is  possible 
that  the  pericarditis  and  abscesses  may  have  been  due  to  pyaemia. 

Sophia  G.,  (No.  in  Reg.  5003)  aged  eighteen,  came  to  St, 
Mary's  on  June  15,  1855,  Avith  debility  and  pericarditis.  The 
only  illness  she  was  aware  of  having  had  was  chorea  at  four  years 
old,  which  had  not  since  recurred.  Her  pericarditis  relapsed 
and  got  worse,  and  the  chorea,  so  long  absent,  returned  again. 
She  died  worn  out  on  July  21. 

Hannah  M.,  (No.  in  Reg.  746)  a  needlewoman  aged  twenty- 
three,  was  admitted  November  1,  1861.  Her  sister  told  me  she 
had  been  deserted  by  a  lover  the  previous  year,  and  had  gradu- 
ally faded  away  ever  since.  Her  skin  had  got  brown  and 
harsh,  her  body  emaciated,  and  her  mind  sluggish.  She  became 
feverish,  and  a  fortnight  before  admission  exhibited  the  usual 
symptoms  of  chorea.  On  admission  the  jactitations  were  so  bad 
that  she  could  hardly  be  kept  on  the  bed.  No  remedies  were 
of  any  avail,  she  grew  delirious,  and  then  raving,  and  then  com- 
atose, and  died  on  the  9th.  At  the  autopsy  we  found — (first), 
some  old  dry  tubercles  in  the  lungs  and  mesentery,  dating 
probably  from  her  first  pining ; — (secondly),  degenerated  supra- 
renal capsules,  connected,  it  may  be  jiresumed,  with  the  bronze- 
tinted  skin; — (thirdly),  a  scrofulous  tumor  as  big  as  a  filbert 
in  the  lumbar  enlargement  of  the  spinal  cord,  which  probably 
was  recent,  and  was  the  cause  of  the  recent  chorea. 

Two  other  cases  were  not  fatal,  but  were  not  at  all  benefited 
by  anything  they  received  from  the  hospital. 

Sarah  C,  (No.  in  Reg.  24)  aged  twenty-three,  married  and 
full  six  months  pregnant  for  the  first  time,  was  attacked  on 
June  20,  1851,  with  acute  rheumatism  of  left  elbow  and  right 
foot,  and  at  the  same  time  her  right  arm  became  affected  with 
chorea.  She  was  free  from  pericarditis  on  her  admission,  June 
27,  but  got  it  on  the  morrow.  Her  rheumatic  and  cardiac 
symptoms  subsided,  yet  the  chorea  was  as  bad  as  ever  when  she 
went  out  on  July  21.  It  continued  till  her  child  was  born  two 
months  afterwards,  and  then  was  cured.  Had  this  young  woman 
been  in  any  danger,  it  would  have  been  worth  while  to  have  in- 
duced premature  labor  ;  I  have  no  doubt  it  would  have  stopped  the 
chorea,  but  the  remedy  would  have  been  worse  than  the  disease. 


CHOREA.  399 

Robert  F.,  (No.  in  Reg.  804)  aged  eighteen,  son  of  a  medical 
man,  was  transferred  here  from  a  mad-house,  Nov.  30,  1860. 
He  had  practiced  masturbation  from  the  age  of  seven,  but  does 
not  appear  to  have  suffered  in  his  health  till  he  was  sixteen, 
when  he  became  affected  with  chorea  for  six  weeks.  He  then 
remained  well  till  the  end  of  1859,  when  the  disease  Avas  brought 
back  again  by  the  same  filthy  practice  I  have  spoken  of.  It 
was  of  a  peculiar  description,  coming  on  in  paroxysms,  princi- 
pally affecting  the  muscles  of  the  neck,  and  twisting  his  head 
so  far  round  sometimes  as  to  cause  him  to  tumble  down,  scream- 
ing and  barking.  He  had  been  in  a  lunatic  asylum,  for  which 
of  course  he  was  not  a  fit  patient,  and  he  had  subcutaneous  in- 
jections of  morphia  at  St.  George's  hospital  without  benefit. 
Morphia  was  also  tried  here  Avithout  permanent  benefit,  and  also 
cauterization  of  the  urethra.  He  was  discharged  incurable  after 
a  month's  trial  of  various  expedients. 

So  you  see  St.  Vitus'  dance  is  not  always  of  so  little  moment 
as  would  appear  from  the  bulk  of  cases,  and  perhaps  from  all 
the  cases  you  may  Avitness  during  your  novitiate.  You  must 
not  give  an  off-hand  favorable  prognosis,  because  you  do  not 
happen  to  have  seen  a  bad  result. 

I  will  also  use  the  hospital  records  to  point  out  to  you  a  curious 
fact  in  the  history  of  chorea,  which  happens  to  be  illustrated  by 
none  of  the  four  patients  at  present  under  your  eyes,  nor  in 
truth  by  any  admitted  under  my  care  this  session.  I  mean  the 
connection  between  it  and  acute  rheumatism.  Out  of  thirty- 
three  cases  which  I  have  looked  over  in  my  old  case-books,  in 
the  following  six  the  nervous  affection  either  began  during  rheu- 
matic fever,  or  followed  immediately  after  it  before  convalescence 
was  complete,  or  else  rheumatic  fever  succeeded  to  the  chorea. 

Sarah  C,  (No.  in  Register  24)  aged  eighteen,  mentioned  just 
now  as  an  instance  of  the  disease  being  unaffected  by  remedies, 
had  both  ailments  at  the  same  time,  but  Avithout  cardiac  lesion. 

John  J.,  (No.  in  Register  291)  aged  sixteen,  had  chorea  im- 
mediately after  rheumatic  fever.  But  was  also  infested  with 
intestinal  worms  which  might  have  been  the  cause.  There  was 
no  cardiac  lesion. 


400  CHOREA. 

Sophia  G.,  (No.  in  Register  5003)  aged  eighteen,  died  of 
pericarditis,  very  probably  rheumatic,  and  chorea.  I  have  men- 
tioned this  case  before  among  the  fatal  ones. 

Sophia  M.,  (No.  in  Register  6425)  aged  seventeen,  had  chorea 
come  on  in  the  hospital  during  an  attack  of  acute  rheumatism, 
free  from  any  cardiac  complication. 

Eliza  B.,  (No.  in  Register  C437)  aged  seventeen,  had  chorea 
come  on  in  the  hospital  during  an  attack  of  rheumatic  fever,  but 
she  had  no  recent  affection  of  the  heart  detected  then.  When 
again  admitted  for  chorea  in  the  succeeding  year,  there  was  a 
soft  murmur,  systolic  and  probably  angemic. 

Martha  C,  (No.  in  Register  for  1861,  346)  aged  twelve,  was 
admitted  with  chorea.  She  denied  having  had  rheumatic  fever, 
though  she  said  she  had  had  rheumatic  pains.  The  heart  proved 
healthy.  Next  year  she  was  under  Dr.  Sibson's  care  for  rheu- 
matic fever,  and  then  again  the  heart  was  examined  and  found 
healthy. 

You  will  observe,  that  though  the  association  with  rheumatism 
is  evident,  there  is  none  made  out  with  previous  lesion  of  the 
heart.  For,  though  Sophia  G.  had  pericarditis,  yet  the  others 
had  no  cardiac  affection.  Considering  how  very  common  inflam- 
mation of  the  central  organ  of  circulation  is  in  rheumatic  chil- 
dren,* and  that  it  is  at  this  age  that  chorea  usually  occurs,  on 
the  mere  doctrine  of  chances  they  would  often  coincide ;  but  the 
cases  I  have  last  referred  to  show  that  the  constitutional  connec- 
tion is  really  with  the  rheumatism,  and  not  with  the  valvular  or 
pericardial  injury. 

Indeed,  when  you  come  to  consider  that  the  red  contractile 
tissue  in  the  majority  of  cases  of  acute  rheumatism  is  seriously 
affected  in  its  functions,  and  in  some  cases  (muscular  rheumatism) 
is  the  only  tissue  affected,  and  that  chorea  is  manifested  by  a 
want  of  control  of  the  muscular  nerves  over  the  muscles,  a  con- 
siderable light  is  thrown  upon  the  relation  of  two  diseases  at 

*  It  is  dependent  partly  on  the  natural  activity  and  excitability  of  muscular 
fiber  in  young  persons,  partly  on  their  intolerance  of  pain  and  warmth,  and  the 
difficulty  of  keeping  them  from  throwing  off  the  bed-clothes,  and  exposing  their 
chest  to  cold  air. 


CHOREA,  401 

first  sight  so  dissimilar.  They  are  defects  of  vital  function  in 
the  same  part.  In  one  case  the  sensitive ;  in  the  other  the  motor 
function  is  injured. 

I  am  sorry  to  say  no  practical  assistance  in  their  cure  has 
been  afforded  by  the  observation  of  the  connection  between  the 
two  diseases.  I  have,  in  a  few  cases,  applied  to  chorea  the 
same  treatment  I  should  have  applied  to  rheumatism,  namely, 
warmth  and  alkalies,  and  it  seemed  to  me  rather  injurious  than 
beneficial. 


LECTURE    XXXI. 

EPILEPSY. 

Cases  illustrative  of  the  use  of  iodide  or  bromide  of  potassium — 
Suggested  explanation  of  the  benefit  so  derived — Accessory 
treatment. 

(Olinical,  St.  Mary's,  June  20,  1863.) 

The  following  are  the  cases  of  epilepsy  which  have  been  in 
the  hospital  under  my  care  since  January  1. 

Richard  L,,  aged  forty-four,  a  married  groom,  had  never  any 
serious  illness  before  February  20.  On  that  day,  soon  after 
going  to  his  work  at  seven  in  the  morning,  he  felt  giddy,  and 
in  two  or  three  minutes  afterwards  he  became  insensible  and 
fell  on  the  stable  floor  in  a  state  of  insensibility,  during  which, 
as  his  companions  told  him,  he  was  convulsed.  A  similar  access 
occurred  the  night  after,  and  a  third  the  next  day.  This  was 
followed  by  a  succession  of  fits  for  twelve  hours,  with  intervals 
of  from  four  minutes  to  a  quarter  of  an  hour.  After  that  he 
had  about  three  during  each  day.  But  during  the  nights  they 
were  more  frequent,  coming  on  whenever  he  tried  to  go  to  sleep. 
On  the  27th  of  February  he  applied  for  admission,  and  had  an 
epileptic  attack  in  our  board  room.  This  one  was  seen  to  last 
about  five  minutes,  being  accompanied  by  casting  up  and  twitch- 
ing of  the  eyes  and  slight  convulsions.  His  urine  was  natural, 
the  genital  organs  normal  in  function,  and  no  blow  on  the  head 
or  any  other  possible  cause  for  the  fits  detected.  He  had  the 
air  of  a  sober  respectable  man. 


EPILEPSY.  403 

He  was  immediately  put  upon  the  following  treatment: — 

^i  Potassii  iodidi,  gr.  iv, 

Tincturse  eantharidiim,  ^xv, 
Mist,  camphor 86,  Sj, 

ter  die. 
A  small  blister  of  an  inch  circumference  behind  each  ear. 

The  epilepsy  never  recurred,  and  he  entirely  lost  the  feeling 
of  giddiness  and  general  malaise  which  had  been  experienced 
during  its  continuance.  As  his  home  was  in  the  neighborhood, 
he  was  discharged  as  cured  on  March  6,  with  a  determination  to 
come  back  if  he  felt  any  likelihood  of  a  relapse,  to  guard  against 
which  he  was  provided  with  medicine  for  a  fortnight.  [He  has 
not  since  made  his  appearance.     February,  1864.] 

A.  M.,  a  boy  of  twelve,  had  a  cut  on  the  head  by  a  fall  in 
fighting  at  ten  years  old.  After  it  had  healed  he  was  quite  well 
till  last  November.  At  that  date  he  began  to  have  epileptic  fits. 
At  first  they  resembled  faintings,  and  occurred  with  various  fre- 
quency, sometimes  as  often  as  seven  or  eight  times  a  day.  Since 
then  they  have  become  of  a  convulsive  character  and  have  occurred 
mostly  at  night.  "When  they  are  coming  on  it  seems  to  him  as 
if  the  room  were  on  fire,  this  is  succeeded  by  sudden  darkness, 
and  he  knows  no  more.  His  mother  states  that  he  almost  always 
goes  to  sleep  immediately  after.  His  appearance  is  healthy,  and 
there  are  no  worms  to  be  found  in  his  stools,  though  his  mother 
had  given  him  strong  purgatives  and  carefully  examined  the  re- 
sults. There  was  ordered  for  him  on  March  20  the  following 
prescription: 

I^  Potassii  iodidi,  gr.  iv, 

Tinctwse  cantharidum,  lt]y, 
Mist,  camphor 86,  .5j, 

ter  die 

Up  to  March  25  he  had  an  attack  each  day.  His  eyes  were 
fixed,  and  the  pupils  much  contracted  during  them,  and  he  fell 
down,  but  did  not  bite  his  tongue. 


404  EPILEPSY. 

On  April  1  at  dinner  time  there  occurred  a  short  fit,  and 
after  that  no  more.  He  was  discharged  cured  on  the  11th, 
having  taken  no  remedies  beyond  that  named  dnd  two  doses  of 
castor-oil. 

Eliza  D.,  an  unmarried  nurse-maid,  twenty-four  years  of  age, 
was  admitted  by  governor's  order,  May  1,  for  epilepsy.  She 
had  her  first  fit  sixteen  months  previously,  when  she  was  at  the 
Cape  with  her  mistress.  At  first  she  was  not  completely  insen- 
sible, and  had  no  convulsions,  but  soon  the  illness  took  on  a 
more  decided  epileptic  character,  and  latterly  she  has  been 
attacked  more  frequently,  sometimes  as  often  as  two  or  three 
times  a  day.  The  catamenia  have  never  been  quite  regular  to 
time,  but  otherwise  she  has  been  a  healthy  woman,  except  for 
the  epilepsy.  She  is  spare,  brown,  and  intelligent,  without  any 
signs  of  hysteria.     She  was  put  upon  the  treatment  by 

^  Potassii  bromidi,  gr.  xv, 
Mist,  campliorse,  .5J, 

ter  die. 

During  the  night  of  May  5  she  had  two  decidedly  epileptic 
paroxysms,  in  which  she  bit  her  tongue.  The  bromide  of  potas- 
sium was  increased  to  gr.  xx,  and  she  had  no  more. 

Thomas  K.,  a  G.  W.  R.  porter,  was  admitted  on  April  11, 
during  an  epileptic  fit,  which  he  had  in  going  to  his  work  at  four 
in  the  morning.  He  was  treated  with  a  turpentine  enema  and 
a  blister  at  the  back  of  neck,  but  as  he  did  not  wish  to  be  kept 
from  his  work  I  lost  sight  of  him.  However,  I  have  reason  to 
believe  that  had  he  been  ill  again,  he  would  have  returned  to 
the  hospital. 

s 

I  bring  to  your  notice  these  last  four  cases  of  epilepsy  which 
have  been  under  my  care,  because  in  most  of  them  a  similar 
remedy  has  been  used  with  apparently  great  success.  Two 
have  taken  the  iodide  and  one  the  bromide  of  potassium,  and  it 
certainly  seems  to  have  controlled  the  disease  in  an  extraordi- 
nary way. 

Remark   that  all    these    three   epilepsies    are   comparatively 


EPILEPSY.  405 

recent.  I  have,  as  a  rule,  refused  to  admit  long  standing  cases, 
as  causing  a  great  deal  of  trouble  and  expending  in  vain  the  funds 
of  the  hospital.  And  I  think  that  trials  of  all  remedies  should 
be  made  on  recent  cases,  for  confirmed  epilepsy  has  become  such 
a  habit  in  the  system  that  it  may  be  looked  upon  as  incurable. 
Even  there  iodide  and  bromide  of  potassium  will  alleviate  the 
evil.  In  one  case  due  to  an  old  sabre  cut  on  the  skull  so  long 
ago  as  the  Greek  war  of  independence,  and  accompanied  by 
partial  paralysis,  I  gave,  in  consultation  wdth  Dr.  Watson,  iodide 
of  potassium,  and  the  fits  became  not  only  less  frequent  but 
milder.  Another  case  of  fourteen  years'  duration  and  used  to 
recur  every  three  weeks,  has  now  been  nearly  six  months  with- 
out at  attack  under  the  use  of  fifteen  grains  of  bromide  of 
potassium  three  times  a  day. 

This  latter  case  had  tried  to  take  the  iodide,  but  even  in  small 
doses  it  so  soon  produced  its  poisonous  efi'ects,  sore  throats,  irri- 
tative fever,  &c.,  that  it  was  never  fairly  tested. 

Sometimes  we  fail.  I  gave  the  iodide  last  winter  to  a  young 
clergyman  for  epilepsy  of  not  above  a  year's  duration.  During 
three  weeks'  stay  in  London  he  was  indeed  free  from  fits,  but 
on  returning  home  they  recurred  as  ibad  as  ever.  Singularly 
enough  I  had  a  few  years  before  given  this  man  large  doses  of 
iodide  of  potassium  for  non-syphilitic  periosteal  rheumatism, 
and  it  had  acted  like  a  charm.  Is  it  possible  that  the  medicine 
can  have  lost  its  effect  over  one  disease  by  having  been  previously 
used  for  another  in  the  same  patient  ?  At  all  events  he  left  it 
off,  and  when  I  last  heard  he  was  taking,  under  advice,  mercurial 
alteratives  to  act  on  the  liver  and  so  on,  not  apparently  with 
any  advantage. 

This  class  of  neutral  salts  seem  to  have  a  peculiar  restorative 
action  over  the  white  fibrous  tissues.  They  were  first  brought 
under  the  notice  of  the  profession  by  the  effect  of  iodine  in 
scrofulous  diseases  of  the  glands,  and  then  by  their  cure  of 
syphilitic  periostitis.  A  notion  got  into  the  profession  that  they 
had  some  antagonistic,  or  controlling,  or  evacuating  power  ovor 
syphilitic  virus ;  but  the  more  recent  surgical  writers,  such  as 
Mr.  Lee,  think  there  is  evidence  against  that  idea,  and  that  they 


406  EPILEPSY. 

benefit  by  curing  the  disease  arising  out  of  the  presence  of  the 
virus  and  not  by  removing  the  virus  itself.  They  cure  the 
patient's  tissues,  without  specially  affecting  the  Jiiateries  morhi, 
if  we  may  apply  that  misused,  term  to  the  poison  which  is  the 
foreign  cause  of  disease.  You  may  see  proof  of  this  opinion  in 
the  fact  of  the  equal  benefit  which  they  confer  in  rheumatic  and 
other  non-venerial  cases  of  periosteal  disease.  When  recently 
affected,  these  patients  are  restored  to  health  as  readily  as  the 
subjects  of  secondary  syphilis  ;  and  the  apparent  resistance  in 
some  cases  to  the  remedy  is  due  to  the  protracted  nature  of  the 
ailments  ;  just  as  syphilitic  periostitis,  when  it  has  lasted  a  long 
time  without  medical  aid,  is  very  obstinate  also.  On  the  ground, 
that  iodide  of  potassium  has  a  special  restorative  power  over  the 
white  fibrous  tissues,  I  should  expect  most  direct  benefit  from  it 
in  epilepsy  to  those  cases  where  epilepsy  is  due  to  some  lesion 
of  the  membranes  of  the  cerebral  or  other  masses  of  nerve  sub- 
stances, whether  that  lesion  be  temporary  or  permanent. 

But  at  the  same  time  I  have  no  data  by  which  to  doubt  of  its 
curative  influence,  where  the  disease  arises  from  lesed  nutrition 
or  visible  tumors  of  nervous  matter.  It  may  not  improbably 
restore  also  that  tissue  to  healthy  vitality. 

Neither  should  I  be  disposed  to  be  skeptical  of  its  virtue  where 
a  peripheral  cause  exists  for  the  convulsions.  That  peripheral 
cause  may  be  an  altered  state  of  some  fibrous  tissue,  and  it  can 
hardly  act  otherwise  than  through  an  altered  nutrition  of  the 
nerve  or  its  envelopes. 

It  is  also  something  to  say  that  no  permanent  injury  to  health, 
and  scarcely  any  even  temporary  inconvenience  is  ever  wrought 
by  iodide  of  potassium.  Some  persons,  misled  by  an  accidental 
instance  or  two  of  lunatics  having  previous  to  their  lunacy  taken 
this  salt,  have  disseminated  a  notion  that  it  weakens  the  mental 
powers.  At  the  Lock  Hospital  for  syphilis  we  administer  annu- 
ally some  hundred-weights  of  it,  but  have  never  found  such  a 
result  follow.  So  that  there  are  no  patients  affected  with 
epilepsy  on  whom  Ave  are  justified  in  not  fairly  trying  the 
experiment  of  its  use. 

I  need  hardly  tell  you  how  important  hygiene  is  in  the  treat- 


EPILEPSY.  407 

nient  of  epilepsy.  The  measures  most  to  be  insisted  upon  are 
those  specially  connected  with  the  etiology  of  the  disease  in  the 
particular  case.  Should  mental  causes,  such  as  fright,  anxiety, 
disappointment,  lie  at  the  bottom  of  the  evil,  a  complete  change 
of  habits  must  be  enforced ;  and  that  is  easiest  carried  out  by  a 
complete  change  of  residence  and  of  companions.  The  same 
expedient  will  also  powerfully  aid  dietetic  improvements  in 
instances  w^here  the  digestive  track  is  at  fault.  In  such  cases  a 
mild  soluble  animal  dietary,  which  feeds  the  tissues  by  frequent 
nourishment,  without  overloading  the  stomach  by  copious  meals, 
such  as  the  diets  of  our  hospitals,  is  of  the  greatest  importance. — 
of  so  much  indeed,  that  some  even  hesitate  to  accept  hospital 
experience  of  the  action  of  medicines  in  this  disease  as  conclu- 
sive of  their  real  value. 

All  ambitious  intellectual  exertion,  especially  rapid  and  dis- 
cursive reading  and  writing  against  time,  should  be  absolutely 
prohibited.  But  moderate  employment  of  the  thoughts,  espe- 
cially on  familiar  and  interesting  hobbies,  is  useful  in  preventing 
that  stagnation  or  concentration  of  the  mind  upon  itself  which 
is  so  hurtful  in  all  chronic  complaints. 


LECTURE   XXXII. 
HYSTERIA. 

Part  I. — Hysteria  not  fatal,  but  not  therefore  unimportant — 
JS^ot  a  uterine  disorder — Its  pathology  lies  between  mind  and 
body — Its  forms  to  be  divided  according  as  it  approaches  one 
or  the  other — Such  a  division  has  a  direct  bearing  on  the 
treatment — 3Iental  liysteria — Treatment,  restoration  of  volun- 
tary mental  force,  of  cutaneous  circulation,  and  of  emotional 
control — Corporeal  cause  for  hysteria — Treatment,  tonic  to 
mucous  membranes — Effects  of  tea-drinking — Treatment 
dietetic. 

Part  II. — Hysterical  vomiting — Three  cases  in  hospital  com- 
jjared  ivith  some  private  patients — It  is  not  in  strictness  vomit- 
ing— Diagnosis  and  treatment — Tlieir  difficulties — Hysterical 
cough — Contagiousness  of  hysteria. 

Part  III. — Connection  between  hysteria  and  insanity  illustrated 
— Medical  curiosity  about  private  history  of  patients — A  p)hy- 
sician  not  a  co7ifessor. 

Part  IV. — Periods  of  life  pirone  to  hysteria — Blighted  affec- 
tions, lotvering  diseases,  and  climate,  as  causes — Two  cases  of 
hystericcd  loss  of  voice  treated  by  valerian  and  shower-baths — 
Spasmodic  cough  and  spitting  of  blood  in  one  patient — Ad- 
vantages of  auscultatioyi  in  the  diagnosis  of  the  latter. 

Part    V. —  Treatment    by    ice — Treatment    by    bloodletting 

Creneral  conclusions. 

(Part  1.— Clinical,  St.  Mary's,  November  8,  1861.) 

Those  who  rate  the  importance  of  diseases  solely  by  the  space 
they  fill  up  in  the  Registrar-general's  report  of  deaths,  will  care 
very  little  about  the  subject  of  the  present  lecture.     Hysteria 


HYSTERIA.  40y 

does  not  show  its  face  at  all  in  that  book.  The  reason  is,  that 
whenever  it  leads  to  a  fatal  result,  it  qualifies  itself  to  be  classed 
either  as  insanity,  epilepsy,  or  some  organic  lesion  ;  and  thus 
our  registering  friends  who  pay  attention  only  to  what  people  die, 
of,  are  apt  to  ignore  it  altogether.  But  this  is  not  a  practical  way 
of  viewing  the  human  misery  you  are  learning  to  lighten.  The 
sum  total  of  suffering  from  hysteria  to  patients  and  their  friends 
is  very  great,  and  probably  equal  to  that  included  under  most 
of  the  names  followed  by  high  numbers  in  the  lists  of  mortality. 

The  chief  thing  that  should  make  disease  interesting  to  you 
is  the  amount  of  misery  which  it  inflicts,  and  the  likelihood 
there  is  of  your  exertions  alleviating  this  misery  ;  not  the  grati- 
fication of  your  vanity  by  observing  how  the  phenomena  during 
life  are  explained  by  the  post-mortem  appearances.  I  hope  you 
will  not  be  led  by  the  excellent  opportunities  for  the  study  of 
morbid  anatomy  which  student  life  affords  to  rate  that  science 
as  the  only  glass  through  which  you  should  look  at  disease.  It 
is  very  rarely  anything  which  can  be  put  up  in  a  bottle  or  made 
into  an  interesting  preparation,  that  patients  feel,  and  that  it  is 
the  business  of  your  life  to  help  them  to  feel  less.  The  true 
use  of  morbid  anatomy  is  to  teach  the  consequences  of  disease, 
not  the  art  of  healing  it,  and  it  is  the  art  of  healing  which  must 
be  the  prime  object  of  your  work  in  the  hospital  wards,  and 
the  business  of  your  lives.  You  must  not  get  a  habit  of  classi- 
fying ailments  according  to  parts  affected  only,  or  a  great 
many  will  escape  altogether  from  your  nosology,  and  some 
you  will  not  believe  in  at  all  perhaps.  Of  others,  again,  the 
names  will  give  you  altogether  wrong  notions  ;  and  of  these 
hysteria  is  an  instance. 

It  is  seldom  I  ask  you  to  erase  anything  from  your  memory, 
but — will  you  please  to  try  and  forget  for  the  nonce  that  hysteria 
is  derived  from  the  Greek  work  'varepa  ?  *  That  is  the  readiest 
way  of  avoiding  the  trap  which  the  name  sets  open  for  the  edu- 
cated student.     In  reality  it  has  no  more  to  do  with  the  organ 

*  Hysteria,  with  the  second  syllable  long,  as  usually  pronounced,  means  "  a 
festival  at  which  swine  were  immolated"  {Donnegan),  but  I  suspect  the  original 
designers  intended  the  e  to  be  short. 


410  HYSTERIA. 

of  reproduction  than  it  has  with  any  other  part  of  the  female 
body ;  and  it  is  no  truer  to  say  that  women  are  hysterical  be- 
cause they  have  wombs,  than  that  men  are  gouty  because  they 
have  beards.  You  may  see  daily  in  the  ward  appropriated  to 
uterine  cases  all  sorts  of  pathological  changes  of  the  part  in 
question,  without  any  greater  tendency  to  hysteria  than  in  other 
women  ;  and  on  the  other  hand,  hysterical  women  are  all  around 
you,  among  both  in  and  out-patients,  whose  uterine  functions 
are  perfectly  healthy.  Of  two  women  I  have  examined  who 
were  born  without  any  uterus  at  all,  one  was  hysterical. 

Our  forefathers,  who  invented  the  term  still  used,  seem  to 
have  fallen  in  with  a  popular  notion  that  the  womb  really  danced 
about  into  all  the  strange  places  where  discomfort  is  felt.  They 
allowed  their  patients  to  think  of  that  mysterious  organ  as  now 
starting  up  under  the  left  ribs  and  causing  lumps  and  pain  in  the 
side,  and  properly  enough  therefore  called  "spleen"  by  classical 
writers  of  the  Addisonian  period,  now  jumping  right  up  into  the 
throat  as  a  "  globus,"  and  now  intruding  itself  into  the  brain, 
appearing  like  a  nail  driven  in — a  "  clavus" — over  the  brow 
and  disturbing  the  senses  and  passions.  You  may  easily  con- 
ceive that  the  believers  in  such  superstitions  were  not  trustwor- 
thy practitioners ;  but  you  will  be  equally  bad  if  you  fall  into 
the  error  of  treating  hysteria  as  a  disease  originating  in  the 
womb. 

Observe  impartially  the  phenomena  in  those  cases  which  come 
before  you,  and  you  will  not  fail  to  be  convinced  that  the  defi- 
cient vitality  of  which  hysteria  is  a  manifestation  is  in  that  puz- 
zling part  of  the  circle  of  life  which  lies  between  spirit  and 
matter.  We  know  so  little  about  the  chain  which  connects  the 
two,  that  its  links  are  reckoned  by  us  as  few  and  short,  and  we 
have  no  names  for  any  of  them.  ■  Yet  when  we  see  the  varied 
phenomena  produced  by  breaches  or  impediments  to  the  connec- 
tion, we  are  led  to  feel  the  depth  of  our  ignorance  on  the  sub- 
ject, and  to  conjecture  that  these  abysses  of  incertitude  veil  a 
long  list  of  vital  functions. 

In  default  of  names  for  even  the  healthy  functions  of  this 
part  of  life,  we  must  not  expect  an  accurate  nomenclature  for 


HYSTERIA.  411 

their  aberrations  from  health  ;  and  the  most  we  can  do  in  trying 
to  dassify  forms  of  hysteria,  is  to  trace  how  near  their  origin 
lies  to  one  or  other  extremity  of  the  series  of  vital  actions 
which  are  interfered  with  ;  what  relation  their  phenomena  hear 
on  the  one  hand  to  mind,  and  what  on  the  other  to  body.  We 
shall  thus  have  set  in  a  natural  series  the  varieties  of  the  disease, 
with  pure  insanity  at  the  one  end,  and  epilepsy  traceable  to  or- 
ganic lesion  at  the  other.  Such  a  nosology  has  a  directly  useful 
bearing  on  our  treatment  of  the  patient,  which  I  cannot  affirm 
of  any  other  attempt  at  classification  of  hysteria  that  I  have  ^''et 
seen.  I  say  it  has  a  direct  bearing  on  our  treatment  of  the  pa- 
tient to  observe  in  each  individual  case  whether  the  disease  is 
most  related  to  deviation  from  mental  or  bodily  health ;  for  I 
feel  convinced  that  it  is  only  by  this  observation  that  Ave  can 
avoid  such  disappointment  as  leads  many  in  our  profession  to 
look  upon  hysteria  as  an  opprobrium  medicinse,  which  makes 
them  feel  the  same  sort  of  anger  against  it  that  is  roused  by 
moral  guiltiness,  and  disposes  them  rather  to  punish  than  to  cure 
the  patient  who  has  thwarted  them. 

After  this  unusually  long  introduction  I  proceed  to  the  busi- 
ness of  the  day,  by  calling  your  attention  to  three  cases  we  have 
visited  during  the  last  week  in  the  larger  female  ward. 

The  first  couch  we  come  to  is  tenanted  by  E.  J.,  a  nursery- 
maid aged  seventeen,  who  was  brought  here  from  her  bed  in  her 
night-dress  and  wrapped  up  in  blankets,  as  an  "  urgency"  dur- 
ing the  week.  She  complained  of  dreadful  pain  and  absolute 
loss  of  power  in  the  legs,  so  as  to  be  quite  incapable  of  standing. 
She  said  that  five  days  previously  her  legs  had  been  red  and 
swollen,  and  that  they  had  been  rolled  up  in  "  bandages  twenty 
yards  in  length  ;"  though  in  the  same  breath  she  declared  that 
they  were  so  painful  that  she  could  not  bear  them  to  be  handled, 
and  that  it  made  her  faint  to  have  them  touched.  This  illness 
she  attributed  to  having  caught  cold,  accompanied  by  diarrhoea, 
when  with  her  mistress  at  the  seaside,  whence  she  has  just  come 
back.  She  complained  also  of  stiffness  and  severe  pain  in  the 
muscles  of  the  neck  and  of  pain  in  the  heart,  and  of  excessive 
perspirations.     In  short,  she  gave  a  fair  description  of  the  symp- 


412  HYSTERIA. 

toms  of  an  attack  of  rheumatic  fever,  and  in  truth  she  was  sent 
to  bed  as  a  case  of  rheumatic  fever,   and  so  entered  in  the 
"  Urgency  admission  book."     But  my  eyesight  did  not  let  me 
concur  in  this  diagnosis.     The  legs  and  feet  were  evenly  smooth 
and  white,  and  she  did  not  cry  out  when  any  part  was  handled 
except  the  calves,  to  which   she   said   the  pain   had   retreated. 
Now  the  pain  of  rheumatic  fever   retreats  to  the  joints,  and  not 
the  calves.     Moreover,  there  was  no  swelling  of  the  neck,  which 
she  said  was  so  painful ;  and  on  diverting  her  attention,  the  car- 
diac region  bore  pressure  without  her  flinching.     And  the  flush- 
injr  of  her  face  seemed  not  due   to   fever,  but  rather   to   mental 
excitement.     Then  we  noticed  that  the  inside  of  her  lips   and 
her  tongue  were  pale,  and  that  the  latter  was  indented  by  the 
teeth  ;  while  there  was  a  soft,  soughing  murmur,  such  as  you 
find  in  anaemic  persons,  synchronous  with  the  first  sound  of  the 
heart.     But  what  mainly  led  me  to  the  diagnosis  which  I  formed 
of  hysteria  was  the  expression  of  her  countenance.     She  has  an 
easily  flushed   skin,  delicate  features,  quickly  answering  to  the 
movements  of  the  mind,  and  in  the  eyes  a  peculiar  appearance 
which    requires   a   separate    sentence    to  itself.     The  balls  are 
large,  and  the  sclerotic  of  a  transparent  sky-blue  ;  the  pupil  is 
much  dilated,  giving  a  general  dark  hue  to  a  naturally  light  eye, 
and  the  conjunctiva  is  smooth  and  bright  from  being  overspread 
with  tears  on  every  emotion.     The  eyelids  are  large,  full  towards 
the  outer  canthus,  giving  a  drooping,  appealing  expression  to  the 
face.     I  believe  this  is  what  ladies  technically  call  "  a  sweet  ex- 
pression."    Of  these  several  hysterical  marks,  the  puffiness  of 
the  eyelid  and  the  dilatation  of  the  pupil  are  the  most  constant 
— indeed  are  seldom  absent — and  seldom  deceive  you. 

Her  history  has  oozed  out  in  driblets  during  the  four  days 
she  has  been  here,  and  has  been  made  up  partly  by  a  motherly 
old  woman  in  the  next  bed ;  for  it  excites  her  too  much  to 
attempt  much  cross-questioning.  I  would  commend  to  your 
imitation  this  mode  of  piecing  up  a  history  by  what  can  be 
extracted  from  the  patient  by  those  who  can  listen  at  leisure. 
Excitable  persons  are  prone  to  exaggerate,  to  invent,  to  forget, 
and  to  appear  to  you  impostors  when  cross-questioned  by  a 
stranger. 


HYSTERIA.  413 

It  seems  that  E.  J.  lias  been  in  service  since  she  was  twelve 
years  old,  and  enjoyed  capital  health  till  sixteen  months  ago, 
when  she  had  a  sad  shock.  She  went  home  for  a  holiday, 
having  heard  of  no  illness  in  her  family,  and  found  her  father 
in  his  coffin.  This  completely  upset  her.  She  has  shifted  about 
from  service  to  service,  and  has  always  been  obliged  to  leave 
from  inability  to  get  through  her  duties.  The  first  bodily  symp- 
toms she  perceived  were  languor  and  palpitation  of  the  heart  on 
exertion;  she  then  became  subject  to  "fits"  as  she  calls  them  ; 
if  anybody  made  her  laugh,  she  could  not  stop,  soon  began  to 
cry  and  to  scream,  and  fell  into  very  low  spirits  afterwards. 
During  this  period  the  catamenia  flowed  for  the  first  time  last 
December,  and  appeared  again  in  January :  she  says  that  she 
was  neither  better  nor  worse  for  the  change  of  constitution. 
Since  January  they  have  been  absent. 

This  is  a  case  of  hysteria  arising  from  a  distinctly  mental 
cause,  and  showing  itself  in  mental  symptoms.  The  organs  first 
affected  are  those  which  are  especially  obedient  to  the  emotions 
of  both  pain  and  pleasure.  First,  the  heart ;  then  the  risory, 
lachrymatory,  and  expiratory  muscles.  In  health,  we  know  how 
these  are  affected  by  changes  in  the  mind,  but  are  still  under  its 
control.  When  then  we  find  in  a  patient  that  control  deficient,  and 
when  we  can  trace  the  deficiency  to  a  cause  purely  mental,  it  is 
rational  to  conclude  that  the  broken  link  is  nearer  to  mind  than 
to  matter,  and  it  is  rational  to  let  this  conclusion  govern  us  in 
our  treatment. 

I  would  here  again  warn  you,  as  I  did  at  the  beginning  of  the 
lecture,  against  associating  hysteria  with  the  reproductive  organs 
or  functions.  To  read  some  male  authors  on  this  subject  one 
would  suppose  that  it  was  only  a  euphemism  for  lust.  A  signal 
injustice  is  thus  done  to  the  weaker  sex,  and  they  might  well 
ask,  as  -^sop's  lion  did  of  the  natural  historian,  if  women  wrote 
books  on  the  diseases  of  men  how  would  the  creatures  be  de- 
scribed ?  If  you  study  in  an  unprejudiced  spirit  the  histories  of 
the  numerous  cases  of  hysteria  which  fall  under  your  notice 
you  will  learn  that  the  sexual  instincts  are  not  oftener  the  moral 
cause  of  the  disease  than  any  other  social  circumstances,  and 
27 


414  HYSTERIA. 

that  physically  the  dijfferential  organs  are  less  frequently  at  fault 
than  any  of  the  important  viscera.  Neither  are  lustful  desires 
the  consequence  of  hysteria  any  more  than  they  are  the  conse- 
quence of  all  that  weakens  the  mental  powers,  of  all  that  lowers 
our  species  in  the  scale  of  creation  and  brings  us  nearer  to  other 
animals.  Emotional  hysteria  is  a  primary  disease  of  the  mind 
as  much  as  lunacy  is. 

As  in  lunacy,  so  also  in  hysteria,  there  follow  morbid  pheno- 
mena connected  with  the  manufacturing  viscera.  The  stomach 
loses  its  power  of  digesting  food  enough  to  supply  the  waste, 
and  the  person  becomes  anaemic.  Then  the  destructive  meta- 
morphosis is  checked  too,  the  urea  is  excreted  in  diminishing 
quantities,  and  the  unrenewed  blood  supplies  no  coloring  mat- 
ter, so  that  the  urine  is  pale  and  watery.  In  short,  the  pa- 
tient becomes  anaemic  ;  and  with  ansemia,  of  course,  there  is  a 
deficiency  in  the  sanguineous  excretions  especially.  Thus  in 
this  girl,  as  you  have  heard,  puberty  truly  began  in  spite  of  the 
illness ;  but  power  was  wanting  to  carry  on  its  periodical  evacu- 
ation of  effete  blood.  The  catamenia  flowed  twice,  and  then 
ceased.  Next  to  the  stomach  probably  ranks  the  uterus  in  its 
liability  to  be  affected  by  the  mind — a  fright  may  suspend  the 
catamenia  or  cause  miscarriage  in  a  perfectly  healthy  woman ; 
and  in  female  lunatics  the  courses  are  scarcely  ever  regular — 
so  that  it  is  quite  in  accord  with  analogy  that  the  same  defect 
should  occur  in  the  half-mental  affections  which  we  reckon  as 
hysterical. 

Next  notice  the  treatment. 

First.  She  was  taken  into  the  hosjntal  as  an  in-patient.  You 
will  find  in  practice  that,  however  good  your  theory  of  the  treat- 
ment of  hysteria  may  be,  it  is  much  more  difficult  to  carry  out 
and  much  less  effective  when  the  patients  are  at  home  than  when 
you  can  remove  them  for  a  time  from  their  ordinary  habits  and 
associations.  It  is  not  merely  that  unprofessional  nurses  fail 
to  obey  implicitly  your  orders,  from  misplaced  tenderness  or 
ignorance  ;  but  that  the  patient's  mind,  by  running  in  its  habit- 
ual groove,  and  being  perpetually  subjected  perhaps  to  the  influ- 
ences which  engendered  the  disease,  less  readily  takes  a  turn 


HYSTERIA.  415 

towards  health.  If  you  expect  in  private  practice  to  be  as  suc- 
cessful as  hospital  physicians,  you  must  try  to  imitate  the  cir- 
cumstances they  have  in  their  favor.  This  is  most  easy  in  the 
poorest  and  in  the  richest  classes.  The  first  can  be  sent  into  an 
hospital :  and  with  the  latter  a  thorough  change  of  scene,  under 
the  charge  of  some  judicious  friend,  is  not  difiicult  to  arrange. 
But  this  is  often  next  to  impossible  for  the  families  of  farmers, 
retail  shopkeepers,  curates,  village  doctors,  and  the  like,  from 
the  union  of  a  light  purse  with  a  weighty  feeling  of  independence. 
One  good  plan  that  can  sometimes  be  adopted  to  the  saving  of 
pride  and  pocket  together,  is  to  negotiate  an  exchange  of  patients, 
where  two  families  of  about  the  same  social  standing  are  simul- 
taneously  afflicted  with  an  hysterical  member.  The  relatives  of 
A  can  take  charge  of  B,  and  the  friends  of  B  repay  the  debt  by 
their  care  of  A.  Mere  kindness  even  may  induce  people  to  re- 
ceive on  a  visit  such  inmates,  if  it  is  pointed  out  how  very  valu- 
able the  kindness  really  is,  and  what  a  high  office  of  Christian 
charity  is  thus  fulfilled,  when  a  sick  person,  incurable  at  home, 
is  rendered  curable  by  removal. 

In  the  wealthier  classes  the  complete  renewal  of  mental  asso- 
ciations involved  in  foreign  travel  is  a  mighty  engine  of  cure. 
But  yet  if  an  hysterical  patient  be  sent  abroad  during  conval- 
escence, you  must  not  be  quite  careless  where  you  send  her  to. 
Some  places  enjoy  a  bad  pre-eminence  for  producing  relapses. 
These  are  generally  low-lying  places  of  even  temperature ;  and 
I  suspect  there  is  some  connection  between  malaria  and  the  in- 
duction of  the  disorder.  Rome  is  an  instance  in  point.  I  was 
much  struck,  when  residing  there  a  few  years  ago,  by  the  fre- 
quency with  which  all  diseases  are  modified  by  hysterical  phe- 
nomena. And  one  case  I  saw  of  well-marked  catalepsy,  which 
strongly  impressed  me.  It  occurred  in  an  English  lady  who 
never  had  hysteria  before  in  any  form,  and  who  was  excessively 
frightened  by  the  unfamiliar  symptoms.  It  came  on  within 
twelve  hours  of  her  arrival  on  a  muggy  spring  evening,  when  she 
was  fatigued  by  her  journey,  and  open  to  all  the  injurious  aerial 
influences  of  the  Campagna  Romana.  During  her  stay  she  was 
from  time  to  time  threatened  with  a  recurrence  and  feared  she 


416  HYSTERIA. 

was  a  destined  victim  of  nervous  invalidism  ;  but  on  leaving 
Rome  the  symptoms  vnnished,  have  never  recurred,  and  were 
thus  proved  to  be  wholly  due  to  the  peculiar  climate.  Be  care- 
ful that  your  hysterical  patients  keep  clear  of  the  Eternal  City.* 
Much  harm  is  often  done  by  sending  them  to  travel  in  Italy  with- 
out a  warning  on  this  point. 

Whatever  be  the  scheme  adopted  for  securing  the  change  in 
habitual  trains  of  thought,  the  principle  of  treatment  will  be  the 
same.  You  must  aim  at  bringing  back  the  control  of  the  mind 
over  tlie  body.  A  link  has  been  dropped,  is  becoming  paralyzed 
for  want  of  use,  and  must  be  renewed.  Let  the  patient  be  ex- 
ercised in  voluntarily  obe^nng  specific  orders  for  the  direction  of 
the  will  ;  moving  the  limbs  to  time,  at  first  slowly,  and  after- 
wards with  more  liveliness,  till  at  last  the  culminating  point  of 
dancing  can  be  arrived  at.  This  is  the  crisis  of  the  cure  ;  and 
when  a  girl  can  be  induced  to  join  a  quadrille  in  the  evening, 
you  need  not  fear  a  relapse  into  hysterical  paralysis.  In  the 
hospital  we  are  obliged  to  substitute  "dull  mechanic  pacings  to 
and  fro,"  assisting  in  the  work  of  the  ward,  &c.  ;  but  these  are 
much  better  than  nothing.  The  same  strong  effort  requisite  for 
these  exertions  is  to  be  used  to  restrain  the  tendency  to  hyste- 
rical fits.  The  truth  is  to  be  forced  upon  the  patient  that  she 
can  learn  to  repress  these  manifestations  of  weakness ;  and  with 
the  learning  will  come  the  power,  and  with  the  power  the  absence 
of  occasions  for  exercising  it. 

What  you  have  to  aim  at  is  exactly  the  converse  of  the  arts 
of  the  electro-biologists,  mesmerists,  and  medium-showmen. 
These  persons,  with  devil-like  ingenuity,  find  means  to  induce  a 
form  of  artificial  hysteria  in  subjects  with  a  tendency  to  mental 
disease ;  that  is  to  say,  they  partially  destroy  the  control  which 
the  mind  has  over  the  body,  and  subject  it  to  the  suggestions  of 
their  own  will.     Let  it  be  your  happier  task  to  restore  this  con- 

*  A  reviewer  of  the  second  edition  of  this  volume,  throws  a  doubt  on  this 
accusation  against  Rome.  I  was  not  aware  that  it  was  new  ;  but  if  so  I  am  glad 
to  find  it  confirmed  by  Dr.  Scoresbj  Jackson  in  his  recent  excellent  work  "  On 
Climatology."  He  describes  the  climate  as  productive  of  a  "  morbid  nervous 
sensibility,"  and  afterwards  advises  that  all  cases  "of  perverted  nervous  sensi- 
bility" *  *  *  '^  should  avoid  Rome." 


HYSTERIA,  417 

trol  by  inducing  the  patients  to  exercise  it  for  themselves. 
Above  all  things,  never  be  led  by  curiosity  or  idleness  to  repeat 
the  experiments  alluded  to.  Each  time  that  poor  creatures  are 
so  practiced  upon,  they  become  more  and  more  enslaved  to  the 
morbid  impressions,  till  they  lapse  into  permanent  hysteria  or 
even  insanity.  You  might  just  as  well  give  a  man  pneumonia- 
or  break  his  leg,  for  the  purpose  of  studying  the  consequence. 

Secondly.  Shower-baths  were  ordered  to  he  given  every  morn- 
ing. The  making  up  the  mind  to  the  shock  of  a  cold  shower- 
bath  is  a  capital  exercise  of  the  will.  In  summer  it  is  most 
suitable  ;  and  I  dare  say  you  remember  in  July,  1860,  a  farmer's 
daughter,  whom  our  late  house-surgeon,  Mr.  Ash,  sent  up  from 
Cornwall  with  absolute  paraplegia  of  both  legs.  This  case  ex- 
cited much  amusement  at  the  time,  because  it  had  been  attri- 
buted by  the  girl's  neighbors  to  witchcraft.  It  was  due  to 
hysteria;  and  she  was  ordered  a  shower-bath  twice  a  day,  with 
the  effect  of  enabling  her  to  walk  several  miles  per  diem,  one 
day  to  the  Pantheon,  and  another  round  the  Serpentine,  before 
she  went  home  cured. 

I  say  "cured,"  partly  because  I  have  lately  heard  from  Mr. 
Ash  of  her  really  being  so,  and  partly  also  because  I  should 
anticipate  the  best  results  from  the  slow  progress  of  her  improve- 
ment. It  is  sometimes  possible  by  a  strong  mental  emotion  to 
overcome  suddenly  nervous  paralj^sis,  but  these  sudden  recoveries 
are  apt  to  be  followed,  time  after  time,  by  relapses,  and  are 
seldom  lasting.  You  have  all,  I  dare  say,  read  at  school  Hero- 
dotus' story  of  the  dumb  child  of  Croesus,  who  in  a  battle  re- 
gained his  speech,  and  stayed  the  soldier's  uplifted  sw^ord  by 
crying  out  "  Spare  my  father."  Well,  there  was  nothing  mira- 
culous in  this ;  it  was  an  ordinary  instance  of  nervous  dumbness 
cured  by  strong  emotion  ;  but  I  should  have  been  surprised  if 
it  had  been  stated  that  he  continued  able  to  talk.  I  know  a  case 
of  permanent  hysterical  paralysis  which  was  several  times  sud- 
denly cured ;  once  by  the  house  catching  fire,  once  by  the 
patient's  maid  being  struck  down  by  cholera,  once  by  an  obsti- 
nate physician  desiring  her  to  rise  up  and  walk.  After  each  trial 
she  was  able  to  move  about  for  a  few  days,  but  she  relapsed  again 


418  HYSTERIA. 

as  bad  as  ever,  and  remained  paralytic  till  her  death  from  other 
causes.     Gradual  cures,  on  the  other  hand,  seldonj*  relapse,  and  ^ 
are  indubitably  the  most  trustworthy. 

In  winter  a  shower-bath  twice  a  day,  as  ordered  for  the 
Cornish  girl,  would  be  rather  a  strong  measure  ;  and  it  is  better 
to  prepare  the  patients  for  it  by  the  use  of  a  tonic  warm  bath, 
such  as  the  following,  which  you  often  see  me  order: — 

I^  Acidi  hydrochlorici  Siss,  aquse  cahfactse  ad  95°  Fahr. 
congios  xxx,     M.     Fiat  balneum. 

Independently  of  their  effect  on  the  mind,  shower-baths  have 
also  a  good  influence  by  arterializing  the  cutaneous  circulation. 
Their  immediate  action  is  to  drive  the  venous  blood  home  to  the 
heart  and  lungs  ;  and  that  which  takes  its  place  is  arterial,  as 
every  one  knows  who  has  reflected  on  the  pink  cheerful  glow  of 
his  person  while  drying  himself  after  this  morning  luxury. 

Thirdly.  Valerian  was  ordered  to  be  taken  three  times  a  day. 
There  are  several  substances  dowered  with  a  special  action  on 
those  nervous  functions  which  minister  to  the  emotions.  They 
come  fiom  different  kingdoms  of  nature,  and  agree  in  no  one 
poijit  except  in  having  all  a  very  strong  smell.  The  essential 
oils  of  sundry  plants  which  are  the  pride  and  profit  of  the  per- 
fumer, the  rose,  bergamotte,  tuberose,  violet,  hyacinth,  fresh 
hay,  and  some  others  of  the  few  sweet  scents  that  exist  in  this 
world,  are  poisons  to  all  with  a  tendency  to  hysteria,  and  are 
proscribed  by  universal  consent  of  fashion  in  all  places  where  the 
disease  is  endemic.  In  Rome,  you  ought  as  soon  think  of  going 
to  an  evening  party  with  a  drawn  sword  as  with  a  strong-scented 
nosegay,  in  any  hope  of  its  acceptance.  Tea  is  equally  baneful, 
and  the  bad  effect  seems  to  dwell  rather  in  the  essential  oil  than 
in  the  alkaloids  which  it  holds  ;  for  coffee,  which  is  as  rich  in 
theine,  is  by  no  means  so  hurtful.  On  the  other  hand,  the 
bracers-up  of  the  nerves  would  seem  to  have  this  good  gift  in 
recompense  for  their  peculiar  offensiveness  in  their  raw  state  to 
the  healthy  nose — valerian,  assafoetida,  garlic,  castor,  musk,  and 
I  believe  some  others  Avhose  disagreeable  virtues  are  not  familiar 
with  me.  The  first  two  are  the  best ;  as,  though  musk  is  very 
beneficial,  its  high  price  and  the  unbearable  permanence  of  its 


HYSTERIA.  419 

odor,  renders  its  use  inexpedient.  In  hospital,  you  will  gene- 
rally see  me  ring  the  changes  upon  the  following  prescrip- 
tions:— 

I^  Tincturde  valerianse  compositae  5ji  Infusi  Valerianae  ad  5j- 
M.  et  fiat  haustus  ter  vel  quater  die  semendus. 

I^  Assafoetidse  gr.  x  in  pilulis  ter  die  sumenda. 

I^  SpiritHs  ammonise  foetidas  5j  <ix  aqud  ter  die  sumendam. 

But  in  private  practice  more  elegant  substitutions  can  be  made 
to  suit  the  patient's  fancy,  such  as — 

I^   Tincturas  eastorei   ammoniatae  [Pharm.  Dub.)  o'j,  aquae 
fseniculi  ad  Sj ; 
or — 

3^  Pilulae  galbani  compositae,  gr.  x ; 
or — 

I^  Zinci  valerianatis,  gr.  iij  ; 

One  or  other  to  be  taken  three  times  a  day. 

You  will  remember,  I  hope,  which  I  have  often,  indeed  con- 
stantly repeated,  that  medicines,  whatsoever  may  be  their 
powers,  can  never  take  the  place  of  other  treatment.  They  are 
merely  an  aid  and  a  means  by  which  the  essential  principles  of 
restoration  may  be  carried  out ;  but  if  they  be  trusted  to  empi- 
rically, if  the  disease  be  prescribed  for  and  not  the  patient, 
failure  will  attend  your  most  industrious  efforts. 

The  next  case  before  us  is  an  instance  of  hysteria  exhibiting 
a  more  material  ailment  from  a  more  material  cause. 

Maria  E.,  a  muscular  matron  of  forty-two,  Avas  confined  of  her 
eleventh  child  nine  months  ago,  and  had  gone  on  letting  it 
suckle  till  the  other  day.  Very  little  milk  there  was  for  it  I 
should  suppose ;  and  the  only  use  of  the  nipple  must  have  been 
as  a  sort  of  opiate.  Yet  notwithstanding  its  difficulties,  by  dint 
of  other  food  the  baby  has  grown  "a  beautiful  fat"  one  ;  but  the 
mother  has  been  severely  punished  for  kicking  against  the  pricks 
of  instinct.  Four  months  ago  she  was  attacked  by  a  succession 
of  fits,  which  drew  her  arms  and  legs  up  in  convulsions,  and 
took  away  her  voice.  She  was  sometimes  quite  paralytic,  and 
sometimes  lost  her  senses,  but  never  bit  her  tongue.  Then  she 
became  afflicted  with  dyspnoea,  which  even  now  as  she  lies  in 


420  HYSTERIA. 

bed,  cuts  short  her  speech,  and  is  constant  when  she  is  up.  Her 
appetite  is  quite  gone,  so  that  she  loathes  the  sight  of  food.  She 
has  also  excessive  pain  in  the  left  hypochondrium,  •which  often, 
in  her  own  words  "  quite  doubles  her  up,"  but  yet  does  not  arise 
from  flatulence.  The  catamenia  have  returned  at  their  proper 
periods,  in  spite  of  the  illness  brought  on  by  her  too  persevering 
attempt  to  nurse  the  child. 

You  may  see  here  again  the  hysterical  eye',  with  large  pupil, 
clear  sclerotic,  full  upper  eyelid,  and  look  of  appeal  for  sympa- 
thy. This  time  it  occurs  in  a  brunette,  and  in  a  woman  whose 
face  might  have  led  you  to  guess  her  to  be  of  a  stern,  strong- 
minded,  or  ascetic  character. 

Now  the  treatment  here  is  different  from  the  last.  She  was 
ordered  for  medicine,  November  1 — 

R  Tinct.  cinchonse  co.,  5j,  decocti  cinehonse  ad  Sj-  Fiat  Jiaus- 
tU8  ter  die  sumendus. 

She  was  kept  quiet  in  bed,  and  bidden  to  take  a  cup  of  half 
and  half  lime-water  and  milk  every  two  hours. 

My  reasons  for  varying  the  treatment  were  as  follows  : — 
I  looked  upon  the  chain  of  causation  as  arising  thus — (1)  ex- 
haustion ;  (2)  imperfect  gastric  digestion;  (3)  anaemia;  (4) 
innutrition  of  nervous  system,  and  the  consequent  exhibition  of 
its  weakness  in  hysterical  phenomena.  And  I  considered  that 
the  easiest  channel  by  which  to  commence  the  renewal  of  life 
was  the  stomach.  It  would  have  been  useless  to  load  the  poor 
organ  with  a  quantity  of  heavy  victuals,  which  it  could  only 
have  relieved  itself  of  by  rejecting.  But  frequent  small  amounts 
are  not  beyond  its  powers ;  and  if  you  give  these  in  the  form  of 
medicines,  the  patients  will  not  think  themselves  at  liberty  to 
choose  or  refuse,  as  they  do  food.  Medicine  indeed  it  is,  though 
conventionally  not  called  so ;  for  it  is  intended  to  cure  the 
stomach  of  its  anaemic,  inei't  condition,  and  thus  to  give  an 
appetite.  The  cinchona  is  designed  to  have  the  same  effect,  by 
astringing  the  surface  of  the  mucous  membrane,  checking  its 
secretion  of  sticky  mucus,  and  thus  enabling  the  gastric  juice  to 
reach  the  food.  And  you  see  that  between  them  the  effect  is 
brought  about ;  for,  as  we  went  round  to-day,  the  patient  said 


HYSTERIA.  421 

her  desire  for  food  was  coming  back,  and  of  her  own  accord 
asked  for  meat.  The  pain  in  the  splenic  region  was  much  better, 
and  the  dyspnoea  gone. 

Wondrous  is  the  power  of  the  stomach  !  When  in  its  right 
senses,  what  a  restorative  physician  it  is  !  By  the  aid  of  our 
patients'  stomachs  alone  we  can  cure  nine  tenths  of  the  curable 
cases  of  disease.  Persius  dubs  it  a  "Master  of  Arts," — Miigister 
artinm  ingenique  largitor  Venter — I  would  give  it  the  degree  of 
"  Doctor  of  Medicine." 

Another  case  of  hysteria  with  a  traceable  bodily  cause  came 
to  us  on  the  same  day. 

Maria  D.,  a  spinster  of  thirty-tAvo  by  her  own  confession,  but 
I  think  she  is  older,  has  been  a  general  servant  in  a  light  place 
for  seven  years.  She  has  been  happy,  and  has  enjoyed  pretty 
good  health,  interrupted  only  by  occasional  headaches  ;  but  for 
some  time  lately  things  have  seemed  to  annoy  her  more  than 
they  ought  to  do.  Three  months  ago,  she  had  a  bad  "  bilious  " 
headache  which  was  followed  by  some  paroxysms  of  laughing 
and  crying.  Five  weeks  back  she  had  an  attack  of  diarrhoea, 
from  which  she  got  better,  and  went  to  work  again  in  spite  of 
Aveakness,  for  she  was  loath  to  let  her  mistress  want  her.  But 
her  exertion  was  in  vain,  for  she  no  sooner  tried  to  clean  a  grate 
than  she  fell  down  speechless,  and  had  a  succession  of  hysterical 
fits,  losing  her  senses,  but  not  biting  her  tongue.  Then  she 
began  vomiting  everything  she  took,  and  this  had  been  going 
on  for  three  weeks,  and  seemed  to  amount  to  a  complete  rejec- 
tion of  all  her  food  immediately  it  was  swallowed.  When  you 
saw  her,  there  was  excessive  flatulence,  the  air  bursting  up 
from  the  stomach  in  roarino;  eructations  while  one  was  talkins; 
to  her. 

In  this  woman,  the  effect  of  the  wide  pupil  and  sj'mpathetic 
hemiptosis  is  not  hidden  even  by  the  disfigurement  of  blear 
edges  to  the  eyelids;  and  it  quite  accords  with  the  droll  earnest- 
ness of  her  manner,  which  increases  gradually  as  you  let  her  go 
on  talking  about  herself,  leaving  no  doubt  of  her  strong  hys- 
terical diathesis. 

As   to   cause,    that    is   still    more   directly   traceable    to    the 


422  HYSTERIA. 

stomach  than  even  in  the  hist  case.  It  wouhl  seem  that  for 
some  years  she  has  been  becoming  more  and  more  addicted  to 
tea-drinking.  She  confesses  to  caring  for  little  else,  so  long  as 
she  could  get  her  favorite  food  or  physic — or  poison — I  do  not 
know  exactly  how  to  call  it.  Her  mistress  was  quite  angry 
with  her  for  eating  so  little  meat ;  and,  with  a  far-sighted 
economy  not  common  in  her  class  of  life,  took  much  trouble  to 
keep  up  the  health  of  a  faithful  servant.  But  the  weakened 
stomach  refused  meat,  and  she  was  literally  starving  in  the 
midst  of  abundance. 

In  this  case,  diet  will  be  the  cure.  When  we  can  make  our 
patient  a  carnivorous  animal  again,  she  will  be  well.  But  what 
is  the  use  of  diet  or  medicine  when  it  is  all  thrown  up  ? — none. 
With  this  feeling,  at  the  same  time  (Nov.  1)  that  I  ordered  her 
limed  milk  every  two  hours,  I  added  also  an  enema  of  half  a 
pint  of  mutton  broth  four  times  a  day.  On  the  5th,  about  half 
the  liquid  swallowed  was  retained,  and  she  complained  that  the 
anus  was  made  sore  by  the  clyster-tube.  The  enema  was  there- 
fore omitted,  and  the  power  of  resisting  nausea  was  aided  by 
four  minims  of  prussic  acid  every  four  hours.  On  the  7th,  she 
vomited  scarcely  at  all,  and  said  she  would  try  and  keep  down 
a  piece  of  meat.  This  she  has  continued  to  do,  and  may  be  now 
counted  convalescent. 

[This  patient  returned  to  the  hospital  Feb.  1864.  She  had 
been  well  from  the  date  of  her  discharge  till  a  fortnight  before, 
when  she  sat  up  several  nights,  and  was  very  anxious  about  her 
sick  mistress.  This  caused  a  return  of  hysterical  vomiting, 
which  was,  however,  soon  alleviated  by  the  same  means  as 
formerly.] 


(Part  II.— Clinical,  St.  Mary's,  May  16,  1863.) 

I  will  call  your  attention  to-day  to  a  case  of  hysterical  vomit- 
ing, namely  that  of  Hannah  P.,  aged  eighteen,  who  has  been  in 
the  hospital  a  fortnight.  She  is  a  respectable  farmer's  daughter, 
and  seems  to  have  been  much  petted  at  home.     She  has  large 


HYSTERIA.  423 

black  pupils  to  the  eyes,  and  puffy  eyelids,  and  allows  that 
before  her  present  illness  she  used  to  have  hysterical  fits,  but 
not  since  she  has  suffered  for  -what  she  came  here  for,  namely, 
chronic  vomiting.  I  should  rather  call  it  a  rejection  of  food, 
for  it  occurs  immediately  after  food  has  been  taken,  almost 
before  it  is  swallowed.  This  happens  at  every  meal,  and  has 
lasted  a  year  and  a  half,  and  during  that  time  she  has  been  for 
a  short  time  in  her  county  hospital  with  relief  but  not  cure. 
She  has  also  pains  in  the  back  and  in  the  splenic  region.  She 
declared  she  was  unable  to  walk  or  even  to  stand  without  assist- 
ance, and  when  placed  upright  in  the  middle  of  the  room  she 
fell  down  at  first.  Nevertheless,  after  a  scolding  and  a  decided 
command  to  exert  her  will  vigorously,  she  at  last  began  to  put 
one  leg  before  the  other,  and  progressed  a  few  steps  even  on  the 
first  day.  The  catamenia  had  been  absent  three  months,  and 
indeed  had  never  been  established  at  regular  periods. 

There  is  a  peculiarity  about  hysterical  paralysis  Avhich  in  a 
great  many  cases  guide  you  to  its  nature — and  guiding  you  to 
its  nature  is  here  more  than  anywhere  a  most  important  step  in 
the  cure.  When  you  set  the  patient  up  on  the  floor,  assisting 
her  with  one  or  two  hands  or  with  your  hands  under  the  axillae, 
according  to  the  degree  of  paralysis  and  the  amount  of  aid 
wanted,  the  body  is  immediately  thrown  forwards,  and  all  your 
strength  is  called  for  to  prevent  her  falling  on  the  face.  Other 
paralytics  fall  to  one  side  or  the  other,  or  backwards,  and  do  not 
stumble  forward  in  this  way.  This  peculiarity  is  well  marked 
in  the  present  instance,  and  has  aided  the  diagnosis. 

[Hannah  P.,  after  retaining  mutton  chops  and  porter  for  a 
fortnight,  and  exhibiting  her  muscular  powers  by  a  walk  to 
Oxford  Street  and  back,  went  home  Avell  July  13.  I  hear  from 
one  of  my  pupils  that  she  has  this  winter  not  only  relapsed  into 
her  former  condition,  but  has  communicated  it  to  a  neighbor  of 
her  own  age.     Dec.  1863.] 

This  is  an  example  of  that  extremely  troublesome  disease 
"hysterical  vomiting,"  by  which  I  mean  a  vomiting  of  food 
independent  of  any  organic  or  anatomical  alteration  of  tissue, 
and  due  to  mental  or  functional  deficiency  of  the  nervous  power 


424  HYSTERIA. 

of  control.  The  pathology  of  the  disease  seems  to  be  this : — 
when  the  food  enters  the  oesophagus  the  lower  muscular  fibers 
being  deprived  of  proper  cerebral  control  act  too  soon,  and  the 
upper  muscular  fibers  are  too  soon  relaxed,  so  that  the  morsel 
instead  of  being  pressed  downwards  into  the  stomach  is  returned 
back  again  to  the  mouth.  Unlike  other  persons,  the  hysterical 
are  unable  to  check  by  a  strong  voluntary  effort  the  conversion 
of  nausea  into  vomiting;  and  often  if  they  are  able,  they  are 
unwilling  to  do  so  by  reason  of  the  peculiar  perversion  of  their 
minds. 

The  difiiculty  of  the  diagnosis  lies  in  the  proverbial  difficulty 
of  proving  a  negative.  It  is  not  wise  or  honest  to  make  an  off- 
hand statement  that  no  organic  change  of  tissue  exists  to  ac- 
count for  the  phenomenon.  And  moreover  I  believe  that  long 
continued  hysterical  vomiting  may  lead  to  organic  change  by 
the  unnaturally  empty  state  of  stomach  which  it  perpetuates. 
It  may  lead  to  congestion  of  the  mucous  membrane,  and  thus  to 
ulceration.  You  must  Avatch  your  patient  carefully  and  note  all 
indications  of  the  organic  disease  or  the  contrary  before  you 
decide ;  for  though  with  the  hysterical  temperament  it  is  the 
most  common  case  for  no  actual  lesion  to  be  found,  yet  the 
chance  of  it  is  not  entirely  excluded. 

But  the  first  thing  to  do  is  to  observe  whether  the  hysterical 
temperament  exists.  For  this  knowledge  no  guide  is  so  sure  as 
that  peculiarity  of  eye  and  manner  which  I  have  often  described 
to  you,  and  which  is  so  strongly  marked  in  this  instance  that 
there  was  but  little  question  as  to  the  nature  of  the  ailment 
being  at  all  events  much  affected  by  it. 

In  the  treatment  of  Hannah  P.,  I  adopted  a  plan  which  has 
been  justified  by  success,  and  which  is  also  justifiable  on  rational 
and  physiological  grounds.  I  ordered  that  food  should  be  taken 
only  in  small  quantities,  but  frequently,  and  always  in  the  stand- 
ing posture.  She  was  made  to  stand  up  and  eat  every  hour. 
The  object  of  making  the  patient  swallow  only  while  erect  is 
to  give  the  oesophagus  the  aid  of  the  force  of  gravity  and  also 
to  relieve  it  of  that  muscular  effort  necessary  for  its  action  when 
horizontal.     The  method  is  of  essential  importance  in  the  treat- 


HYSTERIA.  425 

nient  of  functional  regurgitation,  and  is  also  not  without  its  use 
in  cases  due  to  organic  change,  ulcerative  or  malignant.  I  am 
surprised  not  to  find  it  alluded  to  in  practical  works  on  the 
subject. 

The  view  proposed  by  cold  shower-baths  is  the  strengthening 
of  voluntary  power.  The  warm  season  we  are  having  has 
allowed  of  their  being  taken  twice  a  day,  but  in  colder  weather 
that  is  often  too  much,  and  may  bring  on  catarrh  or  catarrhal 
rheumatism,  or  catarrhal  sore  throat.  Indeed  one  bath  a  day 
will  sometimes  do  that  in  this  chilly  climate.  A  good  pre- 
cautionary measure  in  females  is  to  guard  the  head  from  the 
water;  for  the  soaking  of  their  long  hair  keeps  it  wet  for  an 
hour  or  more,  and  is  more  apt  to  give  catarrh  than  the  shower- 
bath  itself. 

Hysterical  vomiting  is  more  difficult  of  cure  by  mere  drugs 
than  any  other  manifestation  of  the  diathesis;  for  the  usual 
entrance  for  your  means  of  cure  is  barred  against  you.  I  say 
designedly  "barred,"  because  really  the  articles  swallowed  do 
not  get  into  the  stomach;  they  are  not,  strictly  speaking, 
vomited,  and  the  phenomena  are  in  fact  more  analogous  to 
those  of  oesophageal  stricture.  For  this  reason,  the  emaciation 
is  not  so  great  as  in  chronic  cases  where  the  stomach  is  emptied 
by  true  vomiting;  for,  though  thrown  up  immediately,  and  to 
all  appearance  wholly,  yet  in  reality  some  of  the  mass  swal- 
lowed slips  through  the  spasmodic  grasp  of  the  oesophagus, 
descends  into  the  stomach  and  keeps  up  the  nourishment  of  the 
body. 

You  need  not,  therefore,  be  in  so  much  alarm  about  hysterical 
vomiting  as  the  symptom  would  at  first  appear  to  justify.  The 
patient  will  not  be  starved  so  soon  as  the  friends  expect,  and 
there  is  plenty  of  time  for  judicious  treatment  to  be  adopted  and 
to  act. 

In  this  form  of  hysteria,  as  in  those  with  more  obviously 
mental  manifestations,  a  change  of  scene  and  habits  has  a 
marked  efi"ect,  even  although  the  present  circumstances  are  not 
deleterious.  I  do  not  think  you  would  have  seen  so  quick  cure 
of  this  woman  at  her  own  home. 


426  HYSTERIA. 

I  had  a  wliirasical  instance  of  this  last-named  fact  in  a  maiden 
lady  aged  nineteen,  who  was  sent  up  to  me  by  Mr.  Ayres,  of 
Ramsgate.  After  a  preface  of  hysteria,  she  had  suffered  daily 
from  rejection  of  food  during  six  months,  sometimes  throwing 
up  everything  taken,  but  always  unchanged  in  appearance,  thus 
proving  the  vomiting  to  be  oesophageal  and  not  gastric.  Soon 
after  she  came  to  London  the  symptoms  disappeared.  She  went 
home  to  Ramsgate;  and,  being  soon  afterwards  frightened  by  a 
chimney  on  fire,  was  taken  with  her  old  vomiting  again.  She 
returned  to  London  ;  and,  directly  after  I  had  seen  her,  the  same 
day  the  vomiting  ceased  without  any  remedy,  and  she  swallowed 
everything  easily.  It  was  the  most  '■'•  veni,  vidi,  vici"  cure  I 
ever  saw. 

In  cases  where  removal  of  dwelling  is  impossible,  much  care 
and  decision  are  needed  to  enable  you  to  be  victorious.  Dr. 
Woodhouse,  of  Hertford,  called  me  in  to  see  a  case  of  vomiting 
in  an  hysterical  young  married  lady,  where,  either  from  mis- 
placed catamenia  or  congestion  from  retching,  blood  was  thrown 
up  in  considerable  quantities.  We  succeeded  in  entirely  re- 
moving all  food,  and  in  feeding  her  with  beef-tea  enemata  for  a 
fortnight,  after  which  she  gradually  got  back  by  the  steps  of 
spoonfuls  of  milk  to  ordinary  diet,  and  was  cured  completely. 
But  Dr.  Woodhouse  quite  tired  himself  out  by  the  watchfulness 
and  decision  he  had  to  exert  to  get  this  plan  carried  out.  Several 
times  we  were  almost  driven  to  despair  of  success.  You  must 
be  ready  for  a  course  of  decisive  and  sometimes  unrequited  labor 
in  managing  such  cases. 

I  extract  from  my  note-book  of  a  few  weeks  ago  a  case  analo- 
gous to  the  last,  in  so  far  that  the  deficiency  of  healthy  control 
was  exhibited  in  the  same  set  of  nerves,  namely,  the  pneumo- 
gastric,  but  exhibited  in  a  rarer  form. 

>■  Fanny  T.,  aged  twenty-one,  was  last  year  thwarted  in  hopes 
of  gratifying  at  once  her  affections  and  ambition  by  a  very 
advantageous  marriage.  She  is  a  reserved  proud  girl,  and  very 
determined  to  make  no  sign  of  weakness  by  showing  herself  as 
low-spirited  or  hysterical.     She  had  made  up  her  mind  to  be 


HYSTERIA.  427 

independent  of  marriage  altogether,  and  with  a  view  of  securing 
fame  and  fortune  in  the  world  of  letters  had  been  working  very 
hard  at  French,  German  and  Latin  literature.  In  consequence 
her  general  health  was  failing,  the  bowels  became  costive,  and 
the  catamenia  had  been  irregular  the  last  six  months,  occurring 
sometimes  every  fortnight,  and  sometimes  having  intervals  of 
five  or  six  weeks.  She  had  also  got  thin  and  strangely  lost  her 
muscular  strength,  so  that  she  was  tired  with  the  least  walk,  and 
dropped  from  sheer  debility  articles  of  furniture  and  the  like 
which  previously  she  was  used  to  carry  with  ease.  For  the  last 
three  months  she  had  been  troubled  with  a  cough  of  a  peculiar 
loud  barking  character,  very  spasmodic  and  uncontrollable, 
unaccompanied  by  any  pain,  and  not  followed  by  any  expectora- 
tion. At  first  it  used  to  come  on  only  when  she  was  exhausted 
with  actual  exercise,  but  latterly  it  had  got  much  worse,  and 
was  excited  by  even  the  efi'ort  of  speaking  to  any  one  or  by 
seeing  a  stranger,  or  even  by  allowing  her  thoughts  to  dwell 
long  on  any  exciting  subject.  She  had  taken  large  quantities 
of  expectorants,  and  felt  confident  that  they  made  her  worse ; 
the  breast  was  red  and  raw  from  the  application  of  mustard 
poultices  without  even  temporary  benefit  being  derived  there- 
from.    In  fact,  no  medicine  had  done  any  good. 

A  stethoscopic  examination  of  the  chest  showed  the  lungs  and 
heart  to  be  quite  healthy  and  remarkably  well  developed.  But 
what  surprised  me  more  was  the  absence  of  hysterical  manner 
and  aspect,  and  the  extremely  reasonable  way  in  which  she 
spoke  about  her  ailments.  It  was  more  from  the  history  and 
her  own  statements,  than  from  my  own  eyes,  that  I  was  able  to 
guess  at  the  hysterical  diathesis. 

I  look  upon  this  as  an  instance  of  a  strong  external  disposing 
cause  overcome  in  a  great  measure  by  a  still  stronger  will.  In 
a  weaker  minded  woman  it  would  probably  have  resulted  in  the 
extremest  hysterical  phenomena,  in  her  it  acted  only  locally  on 
one  set  of  nerves.  I  dare  say  at  a  future  time  I  shall  be  able 
to  show  you  examples  of  the  same  thing  in  patients  under  your 
own  observation. 


423  HYSTERIA. 

It  is  worth  while  to  notice  in  passing  an  illustration  Ave  have 
also  had  of  the  contagiousness  of  hysteria,  if  the  word  may  "be 
applied  to  communication  by  the  eye- 
Elizabeth  W.,  aged  eighteen,  has  been  in  hospital  many  weeks 
with  several  relapses  of  rheumatic  fever  coming  upon  a  long 
diseased  heart.  She  has  been  all  along  somewhat  disposed  to 
hysteria,  but  never  so  much  as  to  require  special  remedies. 
Our  patient  with  hysterical  vomiting,  Hannah  P.,  being  up  and 
about,  Avas  appointed  by  the  nurse  to  give  the  food  ordered,  and 
was  otherwise  brought  into  familiar  relations  with  her.  In  a 
few  days  Elizabeth  W.  began  to  vomit  also,  and  this  led  me  to 
•  order  valerian.  The  medicine,  a  good  scolding,  and  the  removal 
of  the  intercourse  Avith  Hannah  P.  soon  put  a  stop  to  the  addi- 
tional ailment.  I  have  bidden  her  continue  the  valerian  as  a 
tonic  and  to  prevent  a  relapse. 


(Part  III. — Clinical,  St.  Marys,  February  5,  1863.) 

In  Elizabeth  P.,  Avho  has  just  left  us,  you  have  seen  an  exam- 
ple of  the  connecting  link  between  hysteria  and  insanity.  She 
is  a  servant  out  of  place,  aged  twenty-tAvo,  muscular  and  well- 
made,  but  thin,  and  of  leucophlegmatic  color  and  aspect.  She 
was  sent  in  as  a  case  of  inflammation  of  the  bowels,  and  I  found 
her  in  bed  loudly  complaining  of  violent  pain  in  the  abdomen 
equal  in  external  manifestations  to  that  caused  by  peritonitis. 
But  then  she  lay  twisting  herself  about,  and  when  I  put  my 
hand  on  the  part  she  immediately  contracted  strongly  all  the 
muscles.  People  attacked  Avith  peritonitis  do  not  do  that.  She 
gave  moreover  no  history  of  shiverings,  or  of  any  probable 
cause  of  peritonitis ;  whereas  that  inflammation  is  always  pre- 
ceded and  accompanied  by  rigors,  and  can  generally  be  traced 
to  some  definite  occasion.  Then  she  buried  her  face  in  the 
pilloAV,  avoided  my  gaze,  and  when  pressed  to  look  at  me,  did 
so  with  a  quick  startled  glance  like  a  wild  animal,  and  quickly 
turned  away  her  eyes.  The  pupil  was  widely  dilated,  the 
sclerotic  sky-blue,  giving  the  organ  a  much  brighter  and  blacker 


HYSTERIA.  429 

appearance  than  is  consistent  with  her  blonde  complexion. 
There  was  the  hysterical  droop  and  fullness  in  the  upper  eyelid. 
The  catamenia  were  regular,  and  she  had  no  leucorrhoea.  The 
urine  was  very  pale,  copious,  and  of  a  specific  gravity  only  from 
6  to  7  parts  in  1000  above  that  of  distilled  water.  This  again 
was  fatal  to  the  diagnosis  of  peritonitis.  There  was  a  great 
abhorrence  of  food,  but  no  vomiting,  and  it  did  not  seem  to 
cause  any  inconvenience  when  swallowed.  On  all  these  grounds 
taken  together  I  set  it  down  as  a  case  of  hysteria,  psychical 
rather  than  bodily  in  its  manifestations,  and  depending  rather 
on  moral  than  on  material  causes. 

And  subsequent  information  has  seemed  to  confirm  this  view. 
There  is  some  sad  point  in  her  private  story  which  seems  to 
have  been  the  starting  point  of  her  illness. 

What  that  is  I  do  not  know,  and  moreover  I  do  not  care  to 
inquire ;  for  I  believe  inquiry  would  do  more  harm  than  good  ; 
the  fjict  is  enough.  I  mention  this  in  a  marked  way  in  order 
to  enforce  a  little  bit  of  professional  morality.  You  will  often 
be  tempted  by  natural  sympathy  and  by  curiosity  to  elicit 
romances  of  real  life  from  your  patients.  And  there  is  an 
agreeable  sense  of  responsibility  in  being  the  honorable  guardian 
of  a  secret.  Women  more  especially,  from  an  innate  love  of 
confession,  will  favor  this,  and  are  only  too  ready  to  make  you 
a  confident  of  their  own  and  others'  histories.  Check  your- 
selves and  check  them  directly,  you  have  heard  enough  to  direct 
your  treatment  of  the  case.  Overmuch  sympathy  with  mental 
distresses  and  passions  makes  you  a  less  efficient  medical  man ; 
even  the  appearance  of  sympathy  weakens  your  influence  in 
many  hysterical  cases.  It  is  your  business  to  discourage  a 
morbid  dwelling  on  the  past,  and  to  strengthen  that  English 
reticence  which  leads  us  to  bury  our  sins  and  sorrows  in  some 
out-of-the-way  corner  of  the  memory,  and  to  resent  the  prying 
curiosity  of  medical  or  spiritual  attendant. 

The  diagnosis  of  hysteria  was  confirmed  even  before  ^^e  left 

the  ward  by  the  patient  going   off  into  a  violent  paroxysm  of 

noisy  sobbing  ;  and  the  nurse  told  me  that  a  few  days  afterwards 

something  made  her  laugh,  and  she  was  quite  unable  to  restrain 

28 


430  HYSTERIA. 

the  most  violent  and  painful  cacchinations  for  a  quarter  of  an 
hour.  But  it  also  appeared  that  before  her  admission  she  had 
had  temporary  delusions  on  various  subjects,  and  often  her 
manner  in  the  hospital  was  that  of  a  melancholic.  By  dint  of 
valerian  and  daily  shower-baths  she  got  much  better,  and  was 
able  often  voluntarily  to  keep  off  hysterical  paroxysms,  when 
she  heard  that  having  them  would  entail  a  shower-bath  in  the 
afternoon,  and  at  night  as  well  as  in  the  morning. 

But  her  frightened  insane  manner  she  did  not  loose  till  we 
were  able  to  set  her  to  work  helping  the  nurses  to  wash  the 
crockery,  run  messages,  and  wait  on  the  patients.  This  was 
much  better  than  the  dull  walks  up  and  down  the  garden,  which 
for  some  time  was  all  the  voluntary  exertion  she  could  be  got  to 
make,  and  it  quickly  wrought  a  cure. 


(Part  lY.— Clinical,  St.  Marys,  November  14,  1863.) 

In  the  case  of  Ellen ,  who  left  the  female  wards  two  or 

three  days  ago,  cured  of  hysterical  vomiting  by  valerian  and 
shower-baths,  there  are  a  few  circumstances  worthy  of  practical 
note. 

She  states  that  for  the  last  three  years  she  has  scarcely  ever 
passed  a  month  without  an  attack  of  vomiting  accompanied  by 
great  depression  of  spirits.  These  attacks  however  seldom  last 
above  four  or  five  days,  and  are  usually  cured  by  stimulants. 
Last  August  she  went  to  Eastbourne  along  with  the  family 
where  she  lives  as  cook.  It  was  against  her  will  that  she  went, 
for  she  says  the  seaside  never  agrees  with  her.  While  there 
fihe  had  an  erysipelatous  inflammation  of  the  foot,  Avhich  laid 
Jier  up  for  a  short  time,  and  her  spirits  got  depressed.  Then  a 
very  bad  attack  of  her  old  complaint  came  on;  she  vomited 
-after  all  her  food,  and  continued  to  do  so  till  her  admission  to 
the  hospital,  October  22,  after  she  had  gone  on  suffering  in  the 
.same  manner  for  two  months. 

She  is  a  tall  dark  unmarried  woman  of  thirty-three;  she  has 
•an  imposing  aspect,  with  a  fine  looking  mouth  and  jaw;  but 


HYSTERIA.  431 

yet  she  has  the  hysterical  eye.  Or  at  least  she  had  it  on  admis- 
sion, for  her  expression  is  a  good  deal  altered  since  she  came. 
She  has  never  experienced  paroxysms  of  laughing  or  crying, 
and  is  used  to  conquer  her  depression  of  spirits  by  an  eiFort  of 
throwing  it  off.  She  seems  a  person  of  strong  hysterical  dia- 
thesis checked  by  good  sense  and  powerful  will,  in  whom  the 
diathesis  would  not  have  developed  into  external  manifestations 
without  considerable  motive  causes.  These  motive  causes  may 
be  traced  in  her  history. 

You  observe,  first,  her  age.  A  single  woman  between  thirty 
and  forty  is  in  circumstances  which  have  a  great  influence  on 
the  mind.  She  feels  that  her  chances  of  a  settled  and  natural 
home  are  daily  becoming  less  and  less,  and  that  the  affections 
she  might  expend  on  a  house,  a  family,  and  a  husband,  are 
being  wasted  and  withered.  Hence  their  tendency  to  all  men- 
tal and  semi-mental  ailments. 

Secondly,  early  in  life  her  affections  were  cruelly  deceived 
and  blasted.  Long  ago  she  was  an  unmarried  mother,  and  has 
ever  since  suspiciously  shunned  the  chance  of  a  similar  disap- 
pointment. 

Thirdly,  her  bodily  vitality  was  lowered  by  the  depressing 
illness  of  erysipelas. 

Fourthly,  she  was  in  a  climate  which  tended  to  aggravate 
the  predisponents  already  named.  Many  hysterical  persons 
are  made  worse  at  the  sea-side ;  and  moreover  close  to  East- 
bourne there  are  some  recently  drained  marsh  lands,  whose 
crop  of  malaria  is  in  certain  states  of  the  wind  blown  towards 
the  town.  The  eastern  side  is  especially  exposed  to  this.  Now 
malaria  is  very  poisonous  to  all  nervous  patients ;  it  does  away 
with  all  the  advantage  of  the  fresh  sea-breeze  and  the  change 
of  scene. 

It  is  in  such  cases  as  this,  where  there  is  under  ordinary  cir- 
cumstances a  balance  between  the  disease  and  motive  causes  on 
the  one  side,  and  the  natural  cure  of  strong  will  on  the  other, 
that  j'ou  find  the  more  irregular  forms  of  hysteria  developed. 
And  I  must  frankly  say  they  are  not  easy  to  recognize,  and 
often  difiicult  of  cure. 


432  HYSTERIA. 

I  kept  this  woman  at  first  in  bed  for  a  few  days,  in  order  to 
give  her  perfect  rest,  and  to  enable  her  to  do  without  more  than 
a  very  small  allowance  of  nutriment,  namely,  milk  and  beef-tea 
•Mven  in  doses  of  about  two  ounces  at  a  time.  This  broke  to  a 
great  extent  the  habit  of  vomiting.  Then  she  had  a  teaspoon- 
ful  of  tincture  of  valerian  every  hour,  and  strange  to  say  its 
nauseous  taste  produced  no  nausea.  The  cure  was  completed 
by  a  week's  course  of  daily  shower-baths.  The  woman  herself 
was  much  struck  with  the.  effect,  and  in  spite  of  this  dreary 
weather  said  she  was  determined  to  go  on  with  them  at  home. 
Her  mistress  will  doubtless  accede  to  this  plan  of  keeping  an 
active  servant  in  vigor,  and  armed  with  a  prescription  for  vale- 
rian drops  I  think  our  patient  is  qualified  to  be  her  own  physi- 
cian. 

Compare  this  now  with  the  next  case.  Jemima  T.,  a  house- 
maid, aged  twenty,  has  at  present  hysterical  aphonia.  She  was 
originally  admitted  September  28  for  severe  cedematous  angina. 
She  had  been  salivated  before  admission,  and  was  further  re- 
duced through  the  loss  of  blood  by  leeches,  uncompensated  by 
diet.  For  swallowing  was  so  difficult  to  her,  that  she  was  nearly 
starved.  At  first  I  attributed  the  loss  of  voice,  remaining  after 
the  angina  was  well,  to  paralysis  of  the  vocal  cords  from  the. 
long-continued  oedema  in  the  neighborhood,  especially  as  the 
edges  of  the  glottis  could  be  seen  by  the  laryngoscope  to  be 
somewhat  red.  But  when  we  made  the  attempt  to  apply  galvan- 
ism internally  to  the  cords,  the  true  nature  of  the  aphonia  was 
made  known  to  us  by  having  a  fit  of  a  violent  convulsive  cha- 
racter, in  which  she  screamed  out  lustily  in  a  high  musical  note. 
I  immediately  ordered  her  valerian  and  cold  shower-baths.  She 
has  had  no  more  hysterical  paroxysms,  but  shows  in  the  shower- 
bath  her  talent  for  hallooing,  and  the  voice  is  acquiring  a  tone. 

I  have  brought  forward  this  case  in  order  to  remark  that 
where  any  special  lesion  has  existed,  hysteria  will  very  often 
choose  the  lesed  locality  for  its  manifestation.  This  is  puzzling 
to  you  in  practice,  because  you  do  not  know  when  to  cease 
treating  the  lesion  and  to  begin  treating  the  hysteria.  I  think 
the  general  tendency  is  to  be  too  dilatory  in  changing  the  treat- 
ment. 


4> 


HYSTERIA.  433 

I  have  also  to  remark  an  instructive  clause  in  this  girl's 
history.  She  is  a  native  of  Edinburgh,  or  at  least  was  long 
resident  there,  and  always  enjoyed  very  robust  health  and  high 
spirits,  and  never  felt  tired.  But  on  her  coming  to  London 
eight  months  ago,  this  high  health  almost  immediately  began  to 
fade,  her  nervous  powers  declined,  so  that  she  never  felt  up  to  a 
good  day's  work,  and  she  fell  into  a  state  of  perverted  nervrpus 
sensibility  of  which  you  see  the  phenomena.  I  cannot  help 
attributing  her  illness  to  the  depressing  influences  of  the  climate 
of  London  on  a  person  used  to  the  stern  bracing  air  of  the  East 
of  Scotland. 

[This  girl  regained  her  voice  and  general  health,  and  left  the 
hospital  November  27  to  take  an  opportunity  which  offered  itself 
of  returning  to  Edinburgh.] 

Another  case  of  hysterical  aphonia  came  in  last  week.  Sarah 
L.,  aged  twenty-eight,  lost  her  husband  two  years  ago  after  a 
pulmonary  consumption,  which  had  laid  him  up  for  five  years, 
and  during  which  she  had  nursed  him  assiduously.  She  says 
her  health  has  never  been  strong  since,  though  she  cannot  give 
a  nameto  her  illnesses;  she  has  been  frequently  prostrated  by  a 
feeling  of  excessive  weakness,  but  has  had  no  definite  classifiable 
ailment.  So  she  continued  till  a  fortnight  ago,  when  she  quite 
lost  her  voice,  and  then  was  taken  with  a  severe  cough,  which 
"quite  tore  her  chest  to  pieces."  A  few  days  before  we  saw 
her  she  began  to  spit  up  blood,  but  I  could  not  make  out  from 
her  account  that  the  blood  came  up  with  the  cough.  When  I 
first  examined  her  she  complained  of  exaggerated  pains  all  over, 
and  her  whispering  attempts  at  conversation  brought  on  a 
paroxysm  of  a  violent  spasmodic  character,  like  hooping-cough 
without  the  whoop,  but  it  resulted  in  no  expectoration.  She 
said  she  was  sure  she  was  going  into  a  consumption,  but  percus- 
sion and  auscultation  of  the  thorax  gave  no  evidence  of  any  pul- 
monary or  cardiac  lesion.  The  next  day  she  showed  me  a  quan- 
tity of  slimy  blood  in  a  porringer,  which  she  had  spat  during 
the  night  and  day.  Blood  it  was  truly,  but  yet  it  presented  to 
the  eye  not  exactly  the  aspect  of  that  which  might  come  from 
the  lungs.    It  was  neither  scarlet  nor  frothy,  like  that  so  common 


434  HYSTERIA. 

in  early  tuberculosis,  nor  did  it  consist  of  streaks  in  the  mucus, 
like  that  of  a  more  advanced  stage,  but  it  was  incorporated  with 
and  soaked  into  the  mucus,  more  like  what  jou  have  in  conges- 
tive pneumonia  ;  now  she  certainly  had  not  congestive  pneumonia, 
and  therefore  I  believe  it  does  not  come  from  the  pulmonary 
tissue  at  all.  This  view  is  confirmed  by  the  nurse,  who  says 
the  patient  does  not  cough  it  up,  but  hawks  it  up  very  gently. 
My  own  impression  is  that  it  is  drawn  down  into  the  fauces  from 
the  back  of  the  nose  or  comes  at  lowest  from  the  trachea. 

What  renders  the  case  more  complicated  and  puzzling  is,  that 
her  breath  is  fetid  and  her  tongue  coated  with  a  white  fur,  from 
some  mercurial  medicines  which  she  had  been  taking  before  ad- 
mission. It  is  very  like  the  tongue  of  inflammatory  fever.  But 
then  to  balance  this  element  of  diflSculty  in  the  diagnosis,  she 
has  hysterical  paralysis  of  the  lower  extremities,  being  really 
unable  to  stand,  and  stumbling  forwards  on  the  floor  when  I  left 
her  alone  without  support  in  the  middle  of  the  room.  The  form 
of  paralysis  is  sufliciently  special  to  mark  its  hysterical  character, 
and  compensate  for  the  other  difficult  points  of  diagnosis. 

It  seemed  perhaps  rash  and  cruel,  when  to  a  patient  who  thus 
exhibited  the  symptoms  of  haemoptysis,  cough,  loss  of  voice,  pain 
in  the  chest,  t^uick  pulse,  and  furred  tongue,  I  straightway 
ordered  valerian  draughts  three  times  a  day  and  a  cold  shower- 
bath  every  morning.  But  I  felt  safe  in  my  diagnosis  from  the 
characteristic  appearance  of  the  eyelids  and  the  dilated  pupils. 
She  said  she  was  sure  that  the  shower-baths  would  kill  her;  but 
she  survived  the  first,  and  after  the  second  confessed  it  did  her 
a  great  deal  of  good.  She  is  improving  rapidly,  and  seems  now 
really  desirous  of  being  well,  submitting  without  a  murmur  to 
the  moral  influence  which  I  have  desired  the  nurses  to  exercise, 
in  giving  her  employment,  and  not  allowing  her  to  lie  down  and 
meditate,  as  she  is  prone  to  do. 

This  case  is  an  instance  of  the  enormous  advantage  over  our 

forefathers  which  auscultation  gives  us.    Without  the  stethoscope 

it  would  have  been  a  most  anxious  thing,  nay  almost  impossible, 

for  even  the  most  shrewd  to  have  pronounced  the  negative  opinion 

hat  this  blood  did  not  come  from  the  lungs,  and  that  the  cough 


i 


HYSTERIA.  435 

was  not  produced  by  rapid  tuberculosis.  It  is  an  instance  also 
of  the  reward  which  follows  bold  and  decided  action  in  these 
cases. 


(Part  Y.— Clinical,  St.  Marys,  November  28,  1863.) 

Sarah  L.  went  on  very  well,  having  lost  her  cough  and 
haemoptysis,  and  recovering  the  use  of  her  legs  under  the  ad- 
ministration of  a  cold  shower-bath  twice  a  day,  and  valerian, 
till  November  23.  Then  her  monthly  period  began  in  the  usual 
way,  and  according  to  established  practice  the  ward-sister  ordered 
the  shower-bath  to  be  discontinued.  Sarah  L.  took  to  her  bed 
next  day,  and  began  again  coughing  violently,  and  expectorating 
(really  expectorating  this  time)  a  quantity  of  frothy  bright  blood 
with  each  cough.  There  was  as  much  as  half  a  pint  spat  up  in 
twenty-four  hours.  Yet  the  catamenia  continued  to  flow,  though 
scantily.  I  found  her  on  the  25th  in  bed,  tortured  with  violent 
paroxysms  of  coughing,  and  throwing  up  blood  each  time.  I 
took  a  slab  of  ice,  and  placing  it  on  the  sternum,  directed  her 
to  hold  it  there  with  a  piece  of  flannel.  The  paroxysmal  cough 
and  the  haemoptysis  ceased  forthwith,  and  when  I  saw  her  next 
day,  she  said  she  had  kept  constantly  applying  the  ice,  and  that 
it  always  stayed  the  cough  immediately.  The  catamenia  con- 
tinued. I  bade  that  on  their  ceasing  she  should  resume  the 
shower-baths.  But  this  morning,  when  the  nurse  finding  the 
prescribed  time  for  their  resumption  had  arrived,  ordered  her  to 
have  one,  she  refused,  and  when  remonstrated  with,  still  per- 
sisted in  her  refusal,  though  acknowledging  all  the  good  they 
had  done  her.  Our  necessarily  strict  rules  of  discipline  render 
her,  therefore,  no  longer  a  patient  of  the  hospital,  I  am  sorry 
to  say,  for  I  was  very  anxious  to  see  the  result  of  this  curious 
and  instructive  case. 

Several  examinations  which  I  and  others  made  of  her  chest 
convince  me  that  there  was  no  lesion  of  the  pulmonary  tissue, 
such  as  usually  gives  rise  to  haemoptysis.  I  own  at  first,  and 
even  at  the  time  of  my  last  lecture  to  you,  I  was  suspicious  that 


436  HYSTERIA. 

the  blood  was  produced  by  a  voluntary  effort,  such  as  may  be 
exerted  on  the  back  of  the  fauces,  or  nasal  fossse;  but  observa- 
tion of  this  last  attack  completely  exculpates  the  patient  in  that 
respect.  No  voluntary  effort  could  cause  the  blood  to  be  exuded 
in  such  quantities  into  the  trachea.  Then  its  occurrence  at  the 
menstrual  period  induces  me  to  range  it  in  that  curious,  and  for- 
tunately rare,  class  of  cases  where  the  monthly  hemorrhagic 
nisus  of  the  female  sex,  instead  of  confining  itself  according  to 
the  convenient  arrangement  of  nature  to  the  womb,  an  out-of- 
the-way  and  secret  part,  is  exhibited  in  other  more  conspicuous 
and  troublesome  places. 

Some  of  my  third-year  hearers  may,  perhaps,  remember  a  re- 
markable instance  of  this  misplaced  discharge  in  a  young  woman 
who  was  in  the  hospital  two  years  and  a  half  ago.  She  men- 
struated b}'  the  usual  path,  but  at  the  same  time  had  an  exuda- 
tion of  blood  in  minute  puncta,  from  the  skin  of  the  arms  or 
forehead,  or  legs  or  chest.*  I  called  it  then  a  case  of  "bloody 
sweat,"  for  in  looking  at  her  pale  face,  and  gore-bedabbled  brow, 
a  memory  of  Gethsemane  could  not  fail  to  offer  itself,  and  I  hope 
such  memories  are  not  irreverent.  She  also,  like  our  present 
patient,  was  hysterical,  was  suspected  of  imposition,  and  care- 
fully watched,  but  no  deception  could  be  detected. 

When  that  case  of  catamenial  bloody  sweat  was  admitted,  I 
did  not  know  at  all  how  to  treat  it,  but  I  found  experimentally 
that  free  leeching  the  spots  where  tenderness  gave  notice  of 
threatened  hemorrhage,  not  only  prevented  the  immediately  im- 
minent hemorrhage,  but  gradually  lessened  the  tendency  to  it. 
She  had  seventy  leeches  applied  in  this  way,  and  lost  besides  by 
venesection  twenty-four  ounces  of  blood ;  yet  she  gained  strength, 
and  became  less  hysterical,  and  went  out  nearly  Avell  after  four 
months.  She  had  a  recurrence  last  year,  when  I  saw  her  once, 
and  ordered  her  some  leeches  as  an  out-patient.  And  again  a 
few  weeks  ago  you  saw  her  in  the  ward,  having  come  to  apply 
to  me  for  some  leeches  to  relieve  a  slight  recurrence  in  the  cheek 

*  Full  details  of  this  case  and  the  literature  of  the  subject  are  published  in 
the  "Lancet"  of  March  2,  1861.  I  refrain  from  republishing  it  here  from  an 
anxiety  to  avoid  rare  and  unpractical  cases. 


HYSTERIA.  437 

of  her  old  complaint.     She  stated  that  she  had  been  previously 
free  of  it  for  many  months. 

This  last-named  case  shows  that  in  misplaced  catamenia  with 
hysteria  leeches  will  cure  the  hemorrhage,  without  d;imaging  the 
mental  state ;  and  it  was  my  intention  to  have  tried  an  analogous 
method  of  treatment  in  Sarah  L.'s  case,  but  her  abrupt  departure 
has  defeated  my  design. 

In  all  my  lectures  on  hysteria,  the  conclusions  to  which  I  have 
endeavored  to  lead  you  by  aid  of  the  patients  under  your  eyes 
are — 

1st. — That  it  is  a  disease  (a  word  Avhich  I  always  use  as  synony- 
mous with  deficiency  of  life)  of  the  mind  and  of  the  body  also; — 

2dly. — That  in  some  cases  the  mental,  in  others  the  corporeal 
phenomena  predominate ; — 

3dly. — That  the  predominance  of  one  or  other  must  be  our 
guide,  whether  moral  or  physical  agents  are  most  required  in 
the  treatment; — 

4thly. — That  the  aim  of  our  treatment  of  the  mind  must  be 
the  teaching  our  patients  to  exert  their  will ; — 

5thly. — That  the  organ  which  aids  us  most  in  our  treatment 
of  the  body  is  the  stomach,  and  on  the  proper  regulation  of  this 
viscus  the  success  of  that  part  of  our  practice  will  depend. 


LECTURE    XXXIII. 

SPINAL   PARALYSIS. 

Case  of  paralysis  caused  by  meningitis  of  the  spinal  cord — Action 
of  iodide  of  potassium. 

[Clinical^  St.  Mary's,  June  27,  1863.) 

William  T.,  a  pale-faced,  sandy-haired,  and  delicate-looking 
sliop-boy  of  seventeen,  has  been  under  your  observation  since 
April  10.  He  stated  that  his  father  and  mother  were  alive  and 
healthy,  and  that  he  himself  had  always  been  well  till  Wednes- 
day in  Passion  Week  (April  1),  when  he  had  to  carry  a  heavy 
load  on  his  shoulders;  while  thus  employed,  his  foot  slipped  and 
he  fell  down  against  a  wall,  but  did  not  knock  his  back  or  bruise 
himself.  About  two  o'clock  the  following  afternoon  pain  came 
on  suddenly  in  the  lower  part  of  the  loins.  He  however  went 
on  with  his  work  that  day;  he  had  a  holiday  the  next,  being 
Good  Friday,  and  worked  again  on  Easter  Eve.  But  on  Easter 
Sunday  the  pain  was  so  bad  that  he  took  to  his  bed,  and  lay 
there  till  the  Thursday  after,  when  he  got  up  and  sought  medical 
advice,  as  the  pains  in  the  back  were  so  bad  that  he  could  not 
sleep  at  all.  On  Saturday,  April  11,  he  walked  to  the  hospital, 
and  was  sent  to  bed.  But  though  he  walked,  he  said  his  left 
leg  was  very  painful  and  numb.  He  complained  of  great  thirst, 
the  skin  was  hot,  the  pulse  quick  and  sharp,  and  the  tongue 
thickly  coated  with  a  yellow  fur. 

At  first  he  was  treated  with  chloroform  fomentations  to  the 
loins,  as  for  rheumatic  lumbago ;  but  two  days  after  admission  a 
more  accurate  examination  detected  the  seat  of  the  pain  to  be 
in  the  situation  of  the  last  lumbar  vertebra  at  its  junction  with 
the  sacrum.     The  pain  was  much  increased  by  pressure  and  by 


SPINAL  PARALYSIS.  439 

percussion.  Both  legs  then  appeared  to  be  growing  numb,  and 
there  was  some  difficulty  in  moving  them.  But  the  sphincters 
were  as  yet  unajffected,  and  he  retained  his  urine  and  faeces 
naturally. 

These  symptoms  led  to  the  diagnosis  of  meningitis  of  the 
spinal  cord.  He  was  cupped  to  eight  ounces  at  the  painful 
spot  on  that  and  the  following  day,  and  a  continuous  chloroform 
poultice  was  kept  on  the  sacrum. 

The  paralysis  of  the  legs  increased,  and  sensation  became 
very  deficient,  so  that  he  scarcely  felt  the  hot-water  bottle  at 
his  feet.  He  was  then  (on  the  15th)  ordered  ten  grains  of 
iodide  of  potassium  every  three  hours.  On  the  18th  there  was 
less  inflammatory  fever,  and  the  tongue  was  cleaner.  But  the 
sphincter  of  the  bladder  had  become  paralyzed,  and  the  urine 
trickled  away  involuntarily.  A  catheter  was  then  passed  and 
the  bladder  found  to  be  full,  being  incapable  of  spontaneously 
emptying  itself.  The  urine  drawn  off  was  alkaline,  and  con- 
tained a  small  quantity  of  floating  pus-globules.  Then  he  en- 
tirely lost  command  over  the  sphincter  ani,  as  well  as  over  the 
bladder,  and  lost  also  all  sensation  of  the  passage  of  either  fluid 
or  solid  excrement.  The  urine  was  drawn  off"  three  times  a  day, 
and  constantly  contained  a  large  quantity  of  ropy  pus,  some- 
times quite  obstructing  the  catheter.  The  iodide  of  potassium 
was  continued  in  the  same  doses,  with  no  addition  except  that 
for  two  days  he  had  with  it  a  few  drops  of  tincture  of  cantharides, 
which  was  left  off"  on  the  bladder  being  inflamed,  and  occasion- 
ally a  little  tincture  of  opium,  to  make  the  faeces  more  solid  and 
less  troublesome  to  those  who  cleaned  his  bed. 

The  paralysis  was  at  its  worst  about  the  30th  of  April,  after 
which  it  began  to  mend,  first  in  the  legs,  and  afterwards  in  the 
sphincter  ani,  and  then  in  the  sphincter  vesicae.  The  amend- 
ment in  the  two  latter  seemed  to  be  considerably  aided  by  the 
application  of  blisters  on  the  sacrum  and  above  the  pubes.  The 
patient  can  now  move  his  legs  about  freely  in  every  direction 
as  he  lies  or  sits  on  the  bed,  and  can  voluntarily  retain  his  fasces 
and  urine.  He  can  prevent  himself  from  making  water  for  an 
hour  together.    He  is,  however,  excessively  emaciated  and  weak, 


440  SPINAL  PARALYSIS. 

and  cannot  of  course  walk  about  much.  The  introduction  of  a 
catheter  into  the  bladder  shows  that  it  spontaneously  empties 
itself,  so  that  the  muscular  action  has  completely  returned;  but 
still  there  is  a  certain  amount  of  floating  pus  in  it,  and  it  is  sel- 
dom decidedly  acid.  He  is  taking  decoction  of  uva  ursi  and  cod- 
.iver  oil,  and  improving  daily  in  every  respect. 

[He  left  the  hospital  fat  and  well  at  the  beginning  of  August,  without  any 
purulent  secretion  from  the  bladder  remaining.] 

I  take  this  case  to  have  been  one  of  meningitis  of  the  spinal 
cord,  that  is  to  say,  inflammation  of  the  white  fibrous  coverings, 
and  not  of  the  nervous  tissue  itself.  Instances  of  disease  of  this 
part  are  rare,  and  therefore  one  cannot  of  course  be  very  pedan- 
tically positive  in  reasons  for  a  diagnosis.  My  principal  reason 
was  the  presence  of  local  pain ;  for  in  disease  of  the  spinal  cord 
itself  there  is  no  pain,  as  some  of  you  may  recollect  to  have  seen 
in  the  case  of  a  young  woman  who  died  with  a  scrofulous  tumor 
in  its  lower  part,  last  winter  session.  The  cause  of  her  death 
was  chorea,  but  there  was  no  paralysis  or  local  pain.  Local  pain 
is  also  absent  in  cases  where  hemorrhagic  clots,  tumors,  or  in- 
flammatory softening  occupy  the  central  parts  of  the  cerebral 
mass;  while  it  is  on  the  other  hand  almost  always  present  when 
the  dura  or  pia  mater  are  affected. 

My  clinical  clerk,  Mr.  Philps,  has  shrewdly  suggested  another 
reason  for  the  diagnosis,  namely,  that  the  pain  was  situated  very 
low  down,  to  wit,  in  the  lowest  lumbar  vertebra.  He  says  that 
as  the  cord  has  given  off"  all  its  nerves  and  ended  at  the  level  of 
the  first  lumbar  vertebra,  any  pain  referred  to  a  situation  below 
that  must  be  in  the  envelopes  which  continue  to  surround  the 
bundles  of  nerves,  rather  than  in  the  cord  itself.  And  I  think 
his  reasoning  very  good. 

As  to  the  origin  of  the  disease  in  this  ease  there  is  not  much 
to  help  conjecture.  Possibly  a  rupture  of  some  fibers  of  the 
psoas  muscle  by  the  strain  in  stumbling  under  a  heavy  burden 
may  have  started  an  inflammation  in  the  interior  of  the  pelvis, 
which  affected  secondarily  the  coverings  of  the  sacro-spinal 
plexus,  and  so  spread  upwards.     Possibly  there  may  be  some 


SPINAL  PARALYSIS.  441 

scattered  tubercles  in  the  meninges  of  the  cord  or  its  theca,  just 
in  sufficient  numbers  to  excite  a  curable  inflammation,  but  not 
an  incurable  one.  We  have  not  enough  data  on  which  to  found 
an  anatomical  diagnosis. 

But  we  have  plenty  of  data  for  the  foundation  of  a  therapeu- 
tical diagnosis.  There  was  paralysis  of  the^ower  nerves  of  the 
spinal  cord,  probably  from  inflammation  of  its  meningeal  cover- 
ings. And  on  this  was  based  the  treatment  by  iodide  of  potas- 
sium. You  may  know  from  observations  of  its  use  in  tendinous 
and  thecal  rheumatism,  in  aponeurotic  headaches,  in  chronic 
syphilis,  in  periostitis,  in  inflammation  of  the  eye,  in  hard  en- 
largements of  the  glands  by  disease  of  their  connective  tissue, 
some  of  the  consequences  of  gonorrhoea,  &c.,  how  this  salt  causes 
a  renewal  of  healthy  life  in  white  fibrous  tissue,  without  any 
evacuation  or  destructive  action,  as  is  shown  by  the  patient's  in- 
crease in  weight  during  its  appropriate  employment.  By  its 
action  on  that  tissue  I  explain  its  use  in  such  cases  as  these.  I 
employed  it  once  as  the  only  remedy  in  a  case  of  meningitis  of 
the  brain  in  a  young  man  with  the  best  results,  and  shall  be  dis- 
posed to  trust  to  it  with  equal  confidence  in  future. 


LECTURE    XXXIV. 

SCIATICA. 

Pathology  of  the  disease — Case  of  rheumatic  sciatica — Rokitan 
sky's  description  of  the  morbid  anatomy  of  sciatica — The  dis- 
ease is  a  local  one,  and  therefore  requires  local  remedies — 
Case  of  gouty  sciatica — Relief  from  cupping — Peripheral  pain 
sometimes  more  lasting  than  central  disease — Sciatic  paralysis 
of  bladder — Case  of  ansemic  sciatica — Local  treatment  first 
requisite — Use  of  iodide  of  potassium,  and  of  quinine — Other 
forms  of  sciatica — Other  remedies  besides  those  named — De- 
ductions and  rejiectio7is. 

[Clinical,  St.  Mary's^  January  26,  1861.) 

Three  of  my  patients  now  up  stairs  are  indexed  as  cases  of 
"sciatica."  The  term,  like  "head-ache"  or  "stomach-ache," 
points  out  the  locality  of  the  symptom,  and  is  applied  to  pains 
in  the  great  sciatic  nerve,  whatever  their  nature  or  cause  may 
be,  without  defining  the  morbid  process. 

It  will  better  impress  upon  your  minds  several  important 
points  in  its  pathology  and  treatment,  if  I  recall  to  you  a  few 
of  the  anatomical  relations  of  the  part  affected,  because  upon 
its  anatomical  relations  a  good  deal  depends.  Remember,  first, 
that  the  sciatic  is  the  largest  nerve  in  the  body ; — and  on  that 
score  even  slight  interference  with  it  may  be  expected  to  be 
severely  felt.  Again,  it  is  formed  by  a  union  of  the  sacral 
nerves ;  which,  inside  the  pelvis  (forming  the  sacral  plexus)  are 
covered  on  the  left  side  by  the  rectum,  and  on  the  right  side 
are  in  close  proximity  to  the  caecum ; — henee,  it  is  very  liable 
to  be  influenced  by  the  condition  of  either  of  these  portions 
of  the  intestinal  canal   separately.     It  is  covered  by  a  strong 


SCIATICA.  443 

fibrous  sheath ; — and  may  of  course  be  expected  to  experience 
morbid  states  which  attack  such  membranes.  Moreover  it 
supplies  motion  as  well  as  sensation  to  the  lower  limb ; — 
and  therefore  loss  of  muscular  power  often  follows  its  loss  of 
vitality.  Do  not  forget  also  that  inside  the  pelvis,  branches 
are  sent  from  the  sacral  plexus  to  the  bladder  and  other  pelvic 
viscera ; — and  then  you  will  not  be  surprised  to  find  in  sciatica 
occasional  paralysis  of  the  bladder.  Think,  too,  how  after  it 
passes  beyond  the  border  of  the  pyriformis  muscle,  it  lies  nearer 
the  surface  than  any  great  nerve,  and  goes  straight  from  one  of 
the  warmest  berths  in  the  body  to  one  of  the  coldest ; — so  that 
it  is  soon  afiected  by  changes  of  temperature  is  readily  to  be 
understood. 

The  first  case  which  I  shall  mention  is  a  good  instance  of  the 
last-named  fact.  The  affection  is  strictly  local  and  pretty  recent, 
and  is  clearly  traceable  to  a  local  change  of  temperature  acting 
on  this  part  of  the  body  alone. 

Case  1. — Henry  T.,  aged  twenty-eight,  a  horse-patrol,  of 
temperate  and  regular  habits,  had  been  quite  well  up  to  the 
second  week  in  December,  when  he  got  wet  in  the  saddle  several 
nights  running,  and  his  buttocks  and  thighs  were  much  chilled. 
This  was  followed  by  cold  and  shivering,  but  by  no  particular 
pains  in  the  limbs.  Suddenly,  while  grooming  his  horse,  he  was 
seized  with  a  twinge  in  the  hip,  which  made  him  walk  lame  and 
prevented  his  sitting  on  horseback,  but  did  not  quite  lay  him  up. 
He  continued  with  the  aid  of  a  stick  to  go  through  his  beat 
a-foot  instead  of  riding.  One  day,  and  one  day  only,  before 
Christmas,  the  pain  quite  went  away ;  but,  with  that  exception, 
it  became  worse  and  worse.  Since  December  29,  he  had  been 
unable  to  stand,  so  bad  was  the  pain  ;  and  he  had  had  croton 
oil  rubbed  in  externally,  mustard  poultices,  and  blisters,  without 
the  least  relief.  On  admission,  January  13,  the  tongue,  pulse, 
and  action  of  the  bowels,  were  reported  natural,  the  urine  clear. 
The  situation  of  the  pain,  as  pointed  out  by  one  finger,  was  the 
exit  of  the  sciatic  nerve,  and  pressure  on  that  spot  much  increased 
it.  He  told  us  also  of  a  pain  deep  down  in  the  pelvis,  as  if  it 
lay  at  the  back  of  the  groin. 


444  SCIATICA. 

There  is  here  a  purely  local  disease,  asking  for  local  remedies. 
The  raorhid  anatomy  of  it  I  cannot  describe  from  any  observa- 
tion of  my  own  ;  probably  none  of  us  ever  have  seen,  perhaps 
never  will  see,  the  necropsy  of  a  person  who  dies  durino;  sciatica ; 
it  is  not  itself  deadly,  nor  does  it  accompany  deadly  diseases. 
But  Professor  Rokitansky  describes  the  siieath  of  the  nerve  as 
filled  with  a  yellowish  gelatinous  fluid,  and  as  having  its  blood- 
vessels injected  in  sciatica.  This  is  just  what  you  find  in  the 
rheumatic  inflammations  of  other  fibrous  parts,  and  what  a 
general  knowledge  of  pathology  would  teach  us  to  expect;  and, 
therefore,  I  can  easily  believe  it  to  be  the  unseen  state  in  this 
and  similar  cases.  It  is  a  local  disease  asking  for  local  remedies. 
You  will  say,  it  has  been  so  treated  in  this  case,  and  it  has  not 
got  well.  True  ;  but  the  remedies  were,  for  all  that,  of  the  right 
sort ;  perhaps  not  quite  powerful  enough,  and  moreover,  not 
quite  local  enough.  What  does  that  pain  deep-seated  in  the 
pelvis  mean  ?  It  shows  that  the  sacral  plexus  is  afi"ected,  as 
well  as  the  trunk  of  the  nerve ;  that  the  remedies  must  be 
applied  to  that  part  to  have  their  full  efi'ect.  Such,  I  take  it,  is 
its  meaning.  Now,  applications  to  the  skin  of  the  hip  and 
thigh  are  a  long  way  off  the  sacral  plexus,  and  you  would  not 
get  much  nearer  by  placing  them  on  the  grion.  But  you  can 
get  close  to,  indeed  quite  on,  the  seat  of  action,  by  calling  to 
mind  how  the  plexus  is  overlaid  by  the  rectum.  His  former 
treatment,  mustard  poultices,  blisters,  and  croton  oil,  would  be 
rather  difficult  to  apply  to  that  part  certainly ;  but  you  can  use 
an  allied  remedy,  turpentine ;  and  you  can  introduce  it  to  the 
pelvis  either  by  enema  or  by  the  mouth.  The  former  method  is 
the  most  direct ;  but  I  have  chosen  the  latter  in  this  case,  for 
the  mutual  convenience  of  nurse  and  patient.  His  card  records 
the  following  : 

"  Jan.  14. — I^  Olei  Terebinthinse,  olei  ricini,  mist,  acaciae, 
aa  oSS ;  7nist.  camphorw  Sj-  M.    Fiat  haustus  mane  sumendus." 

Jan.  16.  Repetatitr.  19th.  Rep.  21st.  Rep.  24th.  Rep. 
So  that  five  doses  of  turpentine  in  all  have  been  taken.  On 
the  16th  the  pain  in  the  hip  was  much  relieved,  but  he  had  a 
little   strangury  during  the  action  of  the  turpentine.     On  the 


SCIATICA.  445 

19th  he  said  he  felt  better  after  each  dose,  though  the  pain 
came  back  again.  The  strangury  was  much  less  than  at  the  first 
dose.  On  the  23d  he  described  the  pain  during  the  day  as 
"  not  a  third  as  bad  as  it  was."  He  could  cross  one  leg  over 
the  other  in  sitting,  and  could  walk  without  suffering.  But  you 
will  have  seen  that  he  was  still  lame,  and  heard  him  speak  of  a 
kind  of  numbness  running  down  the  thigh.  This  is  a  slight  pa- 
ralysis, very  usual  in  sciatica,  arising  from  the  pressure  of  the 
swollen  sheath  upon  the  nerve.  He  said  the  deep-seated  pain  in 
the  pelvis  was  gone,  and  to- day,  (the  26th)  he  walks  quite  easily 
and  without  lameness.  But,  unfortunately,  the  turpentine,  not 
having  sufficient  employment  in  doing  good,  has  taken  to  doing 
mischief,  and  has  brought  on  strangury  again.  He  has  had  two 
grains  of  opium  as  a  suppository,  which  has  relieved  it  to  a  cer- 
tain extent ;  and,  instead  of  continuing  the  turpentine,  I  have 
ordered  him  to  be  cupped  to  four  ounces  on  the  hip. 

Case  2. — Another  patient  in  the  same  ward,  Francis  B.,  aged 
fifty-three,  has  no  occupation  now,  but  he  tells  us  that  formerly 
he  did  a  business  of  XI, 000  a  year,  and  enjoyed  a  famous  consti- 
tution. Wealth  and  health  were  lost  through  self-indulgence  in 
eating  and  drinking.  He  had  gout  thrice  in  one  foot,  and  once 
in  both  feet,  twenty  years  ago.  Poverty  made  him  temperate, 
but  two  years  ago  he  had  some  money  left  him,  and  "drank  it 
out,"  being  only  stopped  by  a  severe  attack  of  bleeding  at  the 
nose.  Since  then  he  has  not  exceeded,  but  still  had  a  twinge 
of  gout  six  months  ago.  After  this  he  was  quite  well  till  six 
weeks  ago;  at  which  period,  after  having  felt  for  three  days 
pains  flying  about  him,  he  was  attacked,  while  sitting  before 
the  fire,  with  a  stabbing  agony  in  the  back  and  left  hip,  so  bad 
that  he  was  obliged  to  go  to  bed.  It  has  lasted  ever  since,  and 
he  has  generally  kept  his  bed ;  as,  though  he  can  hobble  along 
without  actual  suff"ering,  he  is  in  constant  fear  of  a  twinge.  All 
through  this  last  illness  there  has  been  a  difiiculty  in  voiding 
urine,  and  the  bowels  have  been  costive.  He  has  been  under 
medical  treatment  all  the  time,  and  has  taken  bark  and  quinine 
in  large  quantities,  and  has  had  blisters  on,  without  being  at 
all  relieved. 
29 


446  SCIATICA. 

On  admission,  the  tongue  and  pulse  were  natural.  By  manual 
examination  the  chief  seat  of  pain  was  found  to  be  a  spot  mid- 
•way  between  the  great  trochanter  and  the  tuberosity  of  the 
ischium;  arrd  in  this  part  there  was  much  tenderness  on  pres- 
sure, and  the  patient  had  great  dread  of  its  being  touched. 
There  was  pain  also  skirting  along  the  outside  of  the  fibula,  but 
not  in  any  intermediate  place. 

In  this  case  you  have  seen  a  different  cause  for  sciatica — 
namely,  gout.  But  whatever  the  cause,  the  local  condition  of 
the  nerve  is  probably  much  the  same,  and  is  better  for  local 
treatment  in  all  cases — indeed  it  is  rarely  cured  without  local 
treatment.  The  remedies  given  here  have  been  pretty  active; 
the  patient  came  here  on  the  11th,  and  between  that  date  and 
the  26th  he  has  had  five  half-ounce  doses  of  turpentine,  and  has 
been  cupped  twice  to  six  ounces.  For  four  days  he  was  allowed, 
as  an  experiment,  to  have  every  night  fifteen  grains  of  Dover's 
powder,  which  I  expected  the  turpentine  to  carry  off  safely  by 
purgation  next  morning.  It  did  not  make  him  sleep,  or  appre- 
ciably relieve  the  pain,  so  it  was  left  off;  for,  as  a  rule,  I  do  not 
like  opiates  in  sciatica.  He  had  less  discomfort  on  the  night 
after  it  was  left  off. 

On  the  18th  he  said  he  had  experienced  great  relief  after  the 
second  cupping.  Take  a  hint  from  this — your  second  cupping 
will  often  confer  much  more  marked  benefit  than  the  first. 

"He  felt  pain  in  the  lower  part  of  the  leg,  but  not  in  the  hip 
unless  it  were  touched,"  says  the  case-book.  You  will  observe 
that  where  there  is  pain  in  the  periphery  of  a  nerve,  arising 
from  disease  in  its  trunk,  this  peripheral  pain  will  often  last 
longer  than  that  which  is  at  the  real  seat  of  injury.  Take  care 
to  retain  this  fact  in  your  memory,  as  it  will  often  prevent  you 
throwing  away  uselessly  on  the  branches  those  remedies  which 
should  be  applied  to  the  trunk. 

On  admission,  the  patient  accused  the  bladder  of  some  want 
of  power.  I  have  seen  this  before  in  sciatica ;  and  I  believe  it 
arises  from  the  vesical  branch  of  the  sacral  plexus  being  affected, 
and  therefore  shows  that  the  morbid  condition  has  penetrated 
into  the  interior  of  the  pelvis.     If  it  really  ai'ise  from  that 


SCIATICA  447 

cause,  and  not  from  any  old  stricture,  you  need  not  be  afraid 
of  causing  striinivury  by  turpentine.  You  Avill  have  seen  it 
in  this  case  doing  no  harm,  but  on  the  contrary,  relieving 
the  symptom  -which  arose  from  a  torpid  condition  of  the 
bladder. 

On  the  23d,  he  bore  pressure  on  the  sciatic  nerve  and  walked 
and  moved  the  limb  without  fear,  though  with  a  certain  loss  of 
power.  He  had  remarked  several  times,  that  though  the  pain 
was  relieved  after  each  cupping  and  dose  of  turpentine,  yet  it 
returned  before  the  next.  The  cause  of  the  disease,  the  gouty 
crasis,  remains,  and  must  be  treated,  or  else  he  will  have  the 
sciatica  back  again.     I  have  therefore  prescribed: 

I^  Vini  colchici  ITjxx,  potassi  iodidi  gr.  iv,  mist  camphorse 
oj.     M.  Fiat  haustus  ter  die  sumendus. 

Case  3. — Sarah  B.,  aged  nineteen,  maid-of-all-work,  pale  and 
greasy-faced,  with  cheeks  and  shoulders  covered  Avith  black- 
heads [acne),  Avas  admitted  January  11.  She  has  had  occasional 
pain  in  her  hip  three  yeai's.  It  came  on  first  when  she  was  out 
of  place,  and  had  frequently  got  wet  in  her  feet.  She  has  often 
felt  pains  flying  about  her  limbs,  but  has  never  been  laid  up  with 
any  distinct  attack  of  rheumatism  in  her  hands  or  feet.  She 
often  coughs,  has  been  always  pale,  subject  to  leucorrhoea,  and 
to  pain  in  the  epigastrium  at  night  and  after  food.  Her  bowels 
are  costive,  and  lier  appetite  bad.  She  became  lame  from  sciatica 
a  few  days  before  Christmas,  and  took  to  her  bed  during  the  last 
few  days  of  the  year,  because  the  pain  got  so  much  worse. 
Aithuugh  an  ouL-patient  at  the  hospital,  she  does  not  appear  to 
have  attended  regularly:  so  that  Dr.  Sieveking,  under  whose 
care  slie  w^as,  sent  fur  her  to  come  in.  On  admission,  her  tongue 
was  clean;  the  pulse  was  92,  and  weak;  the  urine  pale.  The 
catamenia  were  stated  to  be  always  regular,  except  for  three 
months,  when  she  was  first  ill,  three  years  ago.  The  seat  of  the 
pain  was  clearly  pointed  out  by  the  finger  to  the  sciatic  nerve, 
and  not  the  hip-joint.  The  heart  and  lungs  seemed  quite 
sound. 

Here  is  a  cause  for  sciatica  the  very  converse  of  the  last :  that 
was  from  eating  and  drinking  too  much,  this  is  from  eating  and 


448  SCIATICA. 

drinking  too  little.  Indeed  in  a  further  page  of  the  report  you 
read  a  statement  of  the  girl's  own,  that  "  the  pain  sometimes 
entirely  goes  away,  especially  after  a  good  dinner;  but  always 
comes  back  again,  especially  at  night."  But  though  scanty 
diet  has  been  the  cause  of  her  illness,  yet  full  diet  alone  would 
not  restore  health.  In  point  of  fact,  however  much  she  may 
swallow,  she  cannot  really  eat,  that  is  digest,  enough.  This  is 
shown  by  the  want  of  appetite  and  the  peculiar  dyspepsia;  which 
is  described  as  causing  weight  at  the  epigastrium,  and  inability 
to  lie  on  the  left  side. 

The  local  disease  required  treatment  first;  so  she  was  cupped 
once  to  four  ounces  and  was  purged  with  turpentine  ;  and  she 
took  four  grains  of  iodide  of  potassium  three  times  a  day. 

Five  days  afterwards  it  is  registered  that  "the  pain  in  the 
thigh  is  less  than  it  was,  and  she  is  improved  in  every  way." 

On  the  23d,  she  expressed  herself  as  still  better,  and  was 
walking  about  the  ward.  She  was  put  on  quinine  and  iodide  of 
potassium. 

The  last-named  medicine  I  intend  to  act  locally  when  I  give 
it  in  sciatica.  I  want  it  to  promote  absorption  of  the  yellow 
gelatinous  fluid  which  is  effused  in  the  sheath  of  the  nerve,  and 
which  keeps  up  lameness  by  pressing  upon  it,  just  as  you  may 
benumb  your  finger  by  pressing  the  ulnar  nerve.  Iodide  of 
potassium  has  a  very  peculiar  restorative  action  on  the  vitality 
of  the  white  fibrous  tissues,  whether  they  form  tendons,  sheaths 
of  nerves,  or  periosteum;  as  you  may  see  daily  in  those  parts 
when  they  have  been  injured  by  the  poison  of  syphilis. 

I  do  not  suppose  there  is  any  syphilitic  taint  in  this  ease  to  be 
benefited  by  the  iodide.  Nor,  though  I  give  her  quinine,  do  I 
think  that  the  disease  is  of  malarious  origin. 

Yet  syphilis  and  malaria  do  sometimes  produce  sciatica.  The 
syphilitic  form  is  of  the  same  nature  as  periosteal  nodes,  but  it 
is  identical  in  local  effects  with  rheumatic,  gouty,  or  ansemic 
sciatica.  The  malarious  form  is  purely  neuralgic,  and  I  do  not 
think  it  can  ever  be  accompanied  by  effusion.  It  may  be  dis- 
tinguished by  its  complete  intermittence,  and,  as  far  as  my 
experience  goes,  is  comparatively  rare.     The  patients  usually 


SCIATICA.  449 

have  some  other  consequence  of  the  ague-poison,  which  will  help 
you  to  a  diagnosis. 

Sometimes  there  is  a  dull  kind  of  pain  running  down  the 
course  of  the  sciatic  nerve  in  persons  with  sluggish  costive 
bowels,  which,  unlike  the  forms  I  have  been  describing,  is  not 
worse  at  night,  but  neither  in  the  day  is  it  attended  by  paroxysms 
of  agony,  and  it  is  not  made  worse  by  local  pressure.  This  kind 
of  sciatica  depends,  not  on  the  state  of  the  nerve  or  its  sheath, 
but  on  an  unhealthy  sluggish  condition  of  the  lower  bowels. 
When  on  the  right  side,  it  is  due  probably  to  accumulation  of 
faeces  in  the  ceecum ;  when  on  the  left  (which  is  the  most  usual 
case),  to  piles  in  the  rectum,  and  the  consequently  congested 
state  of  the  blood-vessels.  It  is  also  not  made  worse  by  exercise ; 
indeed,  I  think  it  gets  well  sooner  when  the  patient  is  obliged 
to  move  about.  And  for  this  reason  you  do  not  see  examples  of 
it  in  the  wards,  for  it  is  better  treated  in  the  out-patient  depart- 
ment; whereas  in  the  cases  with  which  I  have  been  illustrating 
the  subject  absolute  rest  is  essential. 

I  do  not  like  in  clinical  lectures  to  speak  of  treatment  or  of 
forms  of  disease  not  at  the  time  under  your  notice,  and,  there- 
fore, I  will  not  say  more  about  malarious,  syphilitic,  and  costive 
sciatica.  But  I  think  it  will  be  useful,  in  reference  to  the  three 
cases  you  have  been  Avatciiing,  to  notice  a  few  remedies  which 
might  have  been  given  without  glaring  raalpraxis,  but  yet  which 
I  do  not  think  the  best  under  the  circumstances.  In  the  first 
place,  sedatives  might  have  been  considered  desirable ;  and  you 
will  find  in  books  a  long  list,  commencing  with  opium,  of  those 
which  have  been  administered  in  sciatica.  The  very  length  of 
the  list  shows  how  people  have  been  disappointed  with  the  action 
of  one  after  another ;  and  my  own  experience  is,  that  the  bene- 
fit from  them  is  temporary,  fallacious,  and  obstructive  to  the 
final  cure.  The  only  one  thoroughly  unobjectionable  is  the  ex- 
ternal application  of  chloroform.  Blisters  and  acupuncture  are 
remedies  of  similar  intention  to  those  which  I  have  prescribed ; 
not  quite  so  powerful,  but  equally  rational  and  proper.  Plasters 
are  of  no  use  during  the  acute  stage,  but  when  the  patient  is 
getting  about  again,  they  are  a  defence  against  the  cold.     Let 


450  SCIATICA. 

them  l)c  spread  upon  stout  soft  leather  ;  for  it  is  the  leather, 
not  the  '-'•  emplaHtrum,'"  that  does  good,  and  the  kind  that  will 
stick  tightest  answers  best.  Of  electricity  and  baths  I  have  no 
favorable  experience  to  tell.  I  have  never  seen  them  of  use  to 
the  local  disease  after  the  failure  of  those  remedies  Mhich  I  men- 
tion ;  though  I  daresay  mild  cases  may  be  relieved  by  them,  as 
also  by  numerous  other  expedients,  which  I  need  not  detain  you 
by  naming. 

I  will  tell  you  why  I  do  not  name  them.  When  you  have 
once  established  in  your  own  minds  that  one  particular  methodus 
medendi  is  the  most  effectual  for  a  particular  class  of  cases,  you 
should  not  continue  to  retain  in  your  armory,  to  be  used  for  that 
same  purpose,  the  weapons  which  it  has  superseded.  It  will 
merely  burden  your  memory  and  confuse  your  judgment ;  and  it 
throws  in  your  own  path  a  temptation  to  wavering.  Let  new 
weapons  be  tried  by  all  means,  if  to  the  eye  of  reason  they  pro- 
mise well  ;  but  let  all  which  have  once  fairly  proved  themselves 
failures  be  rejected. 

At  the  same  time  be  not  too  ready  to  adopt  as  fixtures  any 
pet  plans  of  treatment.  Let  them  rule  for  the  time,  but  let  them 
be  prepared  to  make  way  for  better  Avhen  they  fail  to  do  all 
that  is  justly  asked  of  them.  Then  let  their  conquerors  occupy 
the  same  post  under  the  same  conditions.  When  you  have  a 
new  remedy  you  want  to  try,  select  some  cases  in  which  your 
already  established  treatment  has  failed,  and  when  you  have 
found  it  succeed  there  several  times,  you  may  fairly  depose 
the  old  monarch  in  favor  of  the  new.  Thus  will  our  art  ad- 
vance. 

The  most  important  moral  which  I  would  draw  from  our  ex- 
perience of  sciatica  is  this :  to  apply  to  local  diseases  the  need- 
ful destructive  remedies  as  locally  as  possible.  Do  not  call  upon 
the  whole  body  to  make  sacrifices  for  a  single  member,  if  you  can 
by  any  means  avoid  such  sacrifices. 

This  rule  applied  to  the  administration  of  destructives  is 
directly  antithetical  to  that  which  should  guide  us  in  the  use  of 
constructive  agents,  where  we   should   prefer   in    every  instance 


SCIATICA.  451 

constitutional  to  local  action.*  Remember  that  in  the  first 
case  we  are  doing  harm  for  the  sake  of  future  good  ;  in  the 
other  we  are  doing  general  good  for  the  sake  of  particular 
good. 

*  On  the  differences  between   constructive  and  destructive  remedies  see  the 
first  and  second  lectures. 


LECTURE    XXXy. 

ALBUMINURIA. 

Indications  afforded  hy  the  presence  of  albumen  in  the  urine,  and 
prognosis  derived  therefrom — Treatment  based,  not  on  ana- 
tomical division  of  forms  of  degeneration  in  the  kidney,  and 
not  on  the  quantity  of  albumen,  but  on  the  circumstances  ac- 
companying its  presence — Remedia  adjuvantia,  viz.,  iron, 
digitalis,  strychnia — Loedentia,  viz.,  mercury,  alcohol — When 
each  are  justifiable — Treatment  of  dropsy  by  baths,  jalap,  cream 
of  tartar,  elaterium,  and  acupuncture — Sloughing  of  skin,  how 
to  be  treated. 

The  presence  of  albumen  in  the  urine  (albuminuria)  is  a 
notice  "wherebj  we  learn  the  partial  death  of  one  of  the  most 
valuable  structures  in  the  body.  It  shows  the  inefficient  state 
of  those  organs  through  which  the  urea  is  separated  from  the 
blood — the  urea,  which  is  a  measure  of  the  amount  of  destruc- 
tive metamorphosis,  a  measure  of  the  amount  of  one  of  the 
most  essential  parts  of  vital  renewal.  The  knowledge  of  this 
partial  death  is  justly  regarded  as  a  most  important  piece  of 
information  for  us  to  gain.  And  you  know  how  easily  and 
quickly  it  is  gained  by  the  familiar  test  of  boiling  and  nitric 
acid. 

Remark  first — it  is  as  a  notice  that  the  presence  of  albumen  in 
the  urine  is  important.  The  quantity  makes  little  difference. 
The  patient  would  be  in  a  sad  way  indeed  if  such  a  small  loss 
were  of  great  consequence  to  him.  It  is  the  mere  fact  of  its 
presence  at  all  that  so  much  affects  our  prognosis.  Not  the 
proportion  of  albumen  made  visible  by  our  tests,  but  the  cir- 
cumstances accompanying  the  discovery,  make  that  prognosis 
favorable  or  the  contrary. 


ALBUMINURIA.  453 

One  very  important  particular  to  observe  is  the  permanence 
of  the  symptom.  A  single  experiment  should  never  make  you 
a  gloomy  prophet ;  for  albuminuria  is  sometimes  only  of  a  tran- 
sitory character ;  and  though  that  single  occurrence  may  lead 
you  to  be  anxious  about  the  future  history  of  the  patient,  yet  it 
may  be  years  and  years  before  any  harm  happens. 

You  should  also  search  for  blood.  If  there  is  a  stain  of  it  in 
the  renal  excretion,  or  if  disks  are  to  be  found  by  the  microscope 
in  the  sediment  after  the  specimen  has  stood  quiet  for  half  an 
hour,  you  will  know  that  the  disease  has  not  yet  lasted  very 
long,  and  therefore  is  more  likely  to  be  transitory  than  if  it  were 
of  old  date.  This  is  of  great  prognostic  value  after  scarlatina. 
In  patients  recovering  from  that  complaint  the  absence  of  blood 
from  albuminous  urine  is  a  bad  sign,  as  showing  that  the  kid- 
neys were  probably  unhealthy  before  the  accident  of  the  erup- 
tive fever  ;  while  the  presence  of  a  red  or  dusky  or  smoky  tinge, 
is  an  encouraging  one.  If  the  urine  must  be  albuminous,  it  had 
better  be  sanguineous  as  far  as  prognosis  is  concerned. 

The  secretion  of  a  great  quantity  of  water  is  some  evidence  of 
the  chronic  character  of  the  ailment,  and  is  thus  far  unfavorable  ; 
but  this  phenomenon  is  so  much  varied  by  the  daily  habits  of  the 
patient,  the  state  of  the  skin,  bowels,  &c.,  that  it  is  difficult  to 
give  any  strict  rules  of  prognosis  dependent  thereon. 

The  leading  fact  for  you  to  notice  in  the  examination  of  the 
urine  is  the  quantity  of  solid  matter  which  is  daily  passed. 
The  quantity  of  solid  matter  (fths  of  which  is  urea)  is  practi- 
cally a  direct  measure  of  the  vitality  of  the  secreting  portion  of 
the  organ  from  whence  it  comes  ;  and  you  may  know  that  if 
there  is  a  fair  average  amount  of  that  substance  made  in  the 
twenty-four  hours,  there  is  a  sufficiency  of  healthy  gland  re- 
maining, however  abnormal  the  remainder  may  be.  I  need 
hardly  remind  you  that  the  mode  of  measuring  the  solid  matter 
is  by  the  specific  gravity  of  the  water  checked  by  the  whole 
quantity. 

For  appreciating  the  value  of  that  examination  take  the  fol- 
lowing rules  : — 

1.  The  prognosis  is  best,  if  the  specific  gravity  is  as  high  as 


454  ALBUMINURIA. 

that    of  healthy  urine,   viz.,    1020   to    1030,  and   tlie   quantity 
natural,  about  three  pints  in  twenty-four  hours. 

2.  It  is  next  best,  if  the  quantity  is  diminished  -without  dimi- 
nution of  the  specific  gravity  ; — 

3.  Next,  if  the  specific  gravity  is  diminished  without  diminu- 
tion of  the  quantity  ; — 

4.  Worst,  if  both  specific  gravity  and  quantity  are  diminished 
together. 

In  the  systematic  course  of  lectures  on  medicine,  I  describe 
as  in  duty  bound  the  many  shapes  which  degenerated  kidneys 
assume,  the  "  large  yellow,"  the  large  and  small  "mottled,"  the 
"  granular,"  the  "  cysted,"  large  and  small,  the  "hard,"  the 
"  atrophied,"  and  whatever  other  I  can  find  represented  by  spe- 
cimens in  the  museum,  or  sketched  in  my  portfolio.  I  seldom 
conclude  the  subject  without  being  asked  whether  these  diverse 
forms  are  witnesses  of  diverse  noxious  agencies — whether  some 
arise  from  one  cause  and  some  from  another — whether  some 
impede  one  function  and  some  another — above  all,  whether 
special  remedies  are  needed  for  each.  I  am  forced  in  honesty 
to  answer,  to  the  best  of  my  belief,  No ;  and  to  say  further 
that  it  is  lucky  it  is  so,  for  at  present  our  means  of  diagnosis 
do  not  enable  us  to  find  out  which  form  lies  hid  in  the  body 
of  a  sick  man.  The  light  has  failed  which  it  was  hoped 
microscopic  research  of  the  renal  casts  might  throw  upon  the 
matter,  and  it  is  only  by  a  statistical  observation  as  to  which  is 
most  usual  at  particular  periods  of  life  that  a  rough  guess  can 
be  made.  We  must  not  base  our  treatment  on  post-mortal 
anatomy,  or  we  shall  fail  in  our  duty  to  our  patient. 

Upon  observations  of  the  same  phenomena,  which  form  the 
groundwork  of  our  prognosis,  should  be  grounded  our  therapeu- 
tics also.  We  need  not,  as  a  general  rule,  attend  to  the  propor- 
tion of  albumen  contained  in  the  specimen  of  urine  examined ; 
we  must  not  augment  our  vigor  because  the  coagulum  forms  a 
more  than  usually  solid  clot ;  nor  must  we  consider  it  less  neces- 
sary in  a  case  where  we  can  only  obtain  indications  of  the 
abnormal  contents  by  a  slight  opalescence  insoluble  in  nitric 
acid.     And  knowing  that  the  greater  or  less  amount  of  albumen 


ALBUMINURIA.  455 

present  is  rarcJj  of  practical  importance,  let  us  not  waste  our 
time  and  physic  by  direct  attempts  to  curb  its  evacuation.  We 
may,  for  instance,  Avisely  look  upon  the  administration  of  astrin- 
gents, such  as  gallic  acid  given  with  a  view  to  stop  the  emission 
of  albumen,  as  childish.  We  know  that  not  the  loss  of  albumen, 
but  the  state  of  constitution  of  which  that  loss  of  albumen  gives 
notice,  is  the  real  object  to  be  attended  to,  and  to  be  made  the 
end  of  medication.  One  runs  a  great  risk  of  being  led  off  the 
true  track  by  following  by-ends. 

What,  then,  is  the  essential  nature  of  the  state  of  constitution 
which  leads  to  the  presence  of  albumen  ?  It  is  an  imperfect 
growth,  a  lower  vitalized  state  of  that  epithelial  cell-tissue  which 
separates  the  effete  matters  from  the  blood  in  the  form  of  urea. 
A  portion  of  these  cells  remain  dead,  and,  sticking  in  the  tubuli 
uriniferi,  degenerate  into  fat  mixed  up  with  the  fibrin  derived 
from  the  blood,  and  thus  replace  a  pervious  gland  by  a  solid  and 
obstructive  mass.  Others,  more  luckily  for  the  patient,  are  shed 
in  the  form  of  microscopic  casts  of  the  tubes.  It  is  obvious  that 
the  intention  of  all  successful  treatment  must  be  to  replace  them, 
not  to  prevent  their  being  shed.  The  patient  loses  no  more  by 
getting  rid  of  this  useless  tissue,  than  is  lost  by  the  separation 
of  the  sequestrum  of  a  dead  bone,  and  it  is  as  bad  policy  to  try 
and  avoid  one  as  the  other.  Indeed  the  shedding,  in  contra- 
distinction to  the  degeneration  without  shedding,  is  to  be  looked 
upon  as  a  thing  to  be  wished,  and  need  raise  no  alarm,  if  other 
circumstances  are  in  the  patient's  favor.  In  those  cases  which 
recover,  the  casts  are  sometimes  to  be  found  in  the  urine  after 
the  urea  has  regained  its  normal  proportion,  and  when  albumen 
can  no  longer  be  discovered  in  it. 

The  main  object  of  our  treatment  should  be  to  restore  the 
blood  to  that  sound  vital  condition  which  will  supply  a  healthy 
growth  of  new  epithelium  equal  to  carry  on  the  renal  functions. 
This  is  best  done  by  iron.  Though  I  from  habit  order  the  tinc- 
ture of  the  sesquichloride,  I  am  nowise  bigoted  to  that  prepara- 
tion, and  if  any  reason  can  be  given  for  another  form  of  the 
metal,  I  do  not  object.  The  quantity  of  hydrochloric  acid  in 
the  salt  is  not  sufficient  to  allow  one  to  attribute  any  calculable 


456  ALBUMINURIA. 

efficiency  to  it;  the  iron  is  the  essential  matter,  and  the  more  of 
it  the  patient  can  take  the  better. 

Joined  to  iron,  digitalis  seems  serviceable.  I  suppose  it  must 
act  by  restoring  the  balance  of  the  circulation,  and  so  making 
the  supply  of  the  vital  fluid  more  regular  and  full.  With  dege- 
nerated kidneys  there  is  often  joined  a  like  degeneration  of  the 
heart-muscle,  so  incipient  as  not  to  exhibit  alone  any  symptom, 
yet  possibly  advanced  enough  to  aggravate  other  existing  evils. 
It  is  in  these  cases  of  weak  heart,  especially  with  irregular  pulse, 
that  digitalis  is  so  useful.  From  25  to  50  minims  of  the  phar- 
macopoeial  tincture  daily  is  enough. 

Strychnine  is  also  a  valuable  tonic.  It  may  possibly  act  by 
strengthening  the  muscular  action  of  the  heart.  The  doses 
should  be  small ;  ^i^th  of  a  grain  three  times  a  day  is  enough  to 
begin  upon ;  but  with  many  patients,  to  whom  the  alkaloid  is 
especially  serviceable,  you  may  often  increase  it  gradually  to 
double  that  dose.* 

There  is  no  physical  agent  capable  of  doing  so  much  harm  in 
albuminuria  as  mercur3^  Its  action  as  a  destructive  is  much 
more  rapid  in  this  state  of  the  system  than  in  any  other.  You 
can  almost  see  the  increase  of  the  anaemia  under  your  very  eyes. 
In  advanced  cases  of  renal  degeneration,  after  one  or  two  doses 
sometimes  the  gums  will  show  how  the  tissues  are  melting  away, 
though  there  is  hardly  vitality  enough  to  exhibit  an  increase  of 
normal  metamorphosis. 

Yet  this  poison  carries,  like  the  fabled  toad,  a  jewel  in  its 
head.  Where  the  specific  gravity  of  the  urine,  and  a  quantity 
at  all  approaching  the  normal,  indicate  a  trustworthy  amount 
of  metamorphosis,  you  can  use  this  metamorphosis  Avith  most 
powerful  effect  to  remove  the  dropsies  which  are  so  common  in 
albuminurias.  You  may  save  the  patient's  life  by  an  agent 
whose  full  effect  is  poison  to  him. 

But  remember  you  are  wielding  a  sledge-hammer.  Visit 
your   patient  between  each   blow,  and  watch    its    action   with 

*  It  may  be  remarked  that  the  safest  form  of  strychnine  is  the  hydrochlorate 
dissolved  in  a  solution.  The  dose  is  the  same  as  that  of  the  alkaloid.  It  is  safer 
made  up  in  a  draught  than  in  a  pill. 


ALBUMINURIA.  457 

extreme  suspicion.  Do  not  let  the  blows  be  too  frequent — one 
in  the  twenty-four  hours  is  quite  enough.  And  do  not  wield 
it  against  such  butterflies  as  swelled  ankles  and  puffy  eyelids, 
nor  on  any  but  urgent  cages  unless  you  have  tried  other  means 
first. 

I  have  not  myself  employed  any  forms  of  mercury  besides 
the  bichloride  and  the  blue  pill,  but  I  have  nothing  to  say 
against  other  preparations.  I  usually  give  them  combined  with 
digitalis,  and  sometimes  with  squill ;  that  latter  root  seems  to 
increase  the  quantity  of  water  and  salts  in  the  urine,  which  are 
serviceable  as  a  vehicle  for  the  urea  of  metamorphosis. 

Next  to  mercury,  I  think  alcohol  has  the  most  harmful  power 
in  albuminuria.  Theoretically,  we  may  suspect  the  injury  to 
lie  in  further  checking  the  already  wanting  metamorphosis  of 
tissues.  As  a  matter  of  fact,  you  will  find  under  its  use  the 
skin  becomes  anasarcous,  fluid  accumulate  in  the  serous  sacs, 
soaking  of  the  lungs  producing  dyspncea  and  cough,  poisoning 
of  the  brain  with  ureous  blood,  indicated  by  stupidity,  giddi- 
ness and  coma,  and,  in  short,  all  the  evils  you  most  dread  in 
these  cases.  And  alcohol  has  not,  like  mercury,  a  virtue  which 
makes  you  overlook  its  felony.  It  seems  to  do  nothing  but 
harm  in  that  deficiency  of  life  which  is  the  essence  of  the  disease. 
The  only  reason  which  can  justify  you  in  employing  alcohol 
is,  that  the  mind  and  nervous  system  of  the  patient  happen  to 
have  been  so  long  accustomed  to  its  abuse,  that  when  you  have 
fairly  tried  to  leave  it  off  they  sink  from  want  of  it. 

In  the  last  sentence  I  designedly  used  the  word  '^ abuse" 
instead  of  "wse."  You  may  readily  distinguish  those  who  have 
exceeded  what  is  good  for  them  in  their  employment  of  alcohol 
by  this  very  weakness ;  they  cannot  bear  to  leave  it  off  when  on 
a  bed  of  sickness — the  bond-chains  are  so  welded  on  to  the 
nervous  tissues,  that  in  tearing  them  off  you  tear  away  life  with 
them.  Whereas  a  temperate  user,  who  regulates  the  quantity 
of  alcohol  by  its  benefit  to  his  digestion,  and  habitually  lets 
the  effect  of  each  dose  go  quite  off  before  he  takes  another,  can 
bear  without  inconvenience  to  his  nerves  the  removal  of  his 
accustomed  indulgence.     Be  careful  to  ask  your  patients  if  they 


458  ALBUMINURIA. 

ever  take  alcoholics  in  the  forenoon  or  between  meals,  as,  if  they 
do  not,  you  need  not  in  general  be  at  all  afraid  of  ordering  them 
entirely  to  abstain. 

A  very  important  item  in  the  treatment  of  albuminuria  is 
■warm  clothing,  especially  woolen,  next  the  body.  It  is  not 
merely  the  warmth,  but  the  electric  action  of  the  animal  fabric 
■which  is  beneficial  to  the  skin.  This  is  much  more  necessary  to 
be  insisted  on  than  high  temperature  in  the  house,  for  in  fact  it 
is  not  a  high  but  an  even  temperature  that  is  required,  and  that 
is  best  secured  through  the  normal  retention  of  the  heat  by  such 
sort  of  clothing. 

Dropsy  of  an  extent  to  require  special  treatment  will  scarcely 
ever  come  on  when  patients  conform  to  the  above  treatment. 
But  you  may  find  it  already  existing,  as  happens  with  the 
majority  of  albuminuriacs  admitted  to  hospitals,  so  that  practi- 
cally you  have  as  often  to  treat  it  as  to  prevent  it. 

The  quantity  of  water  excreted  per  urinam  is  defective,  and 
hence  much  good  is  often  done  by  simple  confinement  to  the 
horizontal  position  in  bed,  and  the  administration  of  watery 
drinks  in  greater  amount  than  the  thirst  demands.  Frequent 
doses  of  weak  broth  attain  that  end  very  well.  For  water  is  a 
true  restorative  diuretic  ;  it  increases  the  amount  of  fluid  secreted 
to  a  proportion  greater  than  its  own  bulk,  and  it  also  increases 
the  amount  of  urea  and  salts,  thus  directly  increasing  vitality. 
That  nitre  has  the  same  power  is  rendered  extremely  probable 
by  the  experiments  of  Parkes  and  Dr.  Shirks  (quoted  by  the 
former*),  and  I  therefore  freely  administer  this  neutral  salt  with 
■water  in  all  cases  of  dropsy.  Under  the  use  of  these  means  the 
appetite  improves,  the  lips  become  redder,  and  the  pulse  stronger, 
at  the  same  time  that  the  anasarcous  swellings,  and  sometimes 
even  ascites,  diminish. 

Warm  baths,  soured  with  hydrochloric  acid,  seem  also  useful. 
In  two  chronic  cases  (mild  ones  though)  the  excretion  of  albumen 
in  the  urine  has  disappeared,  as  ■well  as  the  dropsy,  under  their 
employment.  But  I  have  never  ordered  them  alone,  the  patients 
always  having  iron  at  the  same  time  ;  so  that  I  cannot  speak  very 

■*  Paikes  on  the  urine.     "  On  the  urine  in  health,"  chap,  ii,  sect,  iv,  8. 


ALBUMINURIA.  459 

positively  on  the  subject,  except  so  far  as  to  say  that  they  cer- 
tainly do  no  harm  and  probably  do  good. 

While  on  the  subject  of  baths  I  would  remark  that  you  must 
be  careful  not  to  let  them  be  too  hot.  "  The  warmth  of  the 
body"  is  doubtless  a  wise  rule,  but  then  the  warmth  of  the  body 
in  albuminuriacs  is  much  below  tliat  of  j^ours  in  liealth,  and  98 
deg.  Fahrenheit  often  produces  in  them  gasping,  faintness,  and 
exhaustion.  They  bear  sudden  changes  of  temperature  in  the 
direction  of  heat  quite  as  ill  as  in  the  direction  of  cold,  and  92 
deg.  is  usually  quite  high  enough  for  them. 

Hot-air  or  vapor  baths  you  sometimes  see  me  order.  Their 
advantage  is  that  they  can  be  used  where  the  patient  is  so  much 
swollen  as  to  make  getting  up  painful ;  but  the  effect  is  very 
stifling,  even  though  the  head  is  kept  out,  and  is  not  more  power- 
ful in  promoting  the  action  of  the  skin  than  water-baths. 

It  is  only  when  these  means  have  failed  that  I  betake  myself 
to  mercury,  with  the  fear  and  trembling  above  described. 

An  occasional  active  purge  of  jalap  and  cream  of  tartar  will 
often  be  of  service  by  setting  up  absorption  of  the  extravasated 
fluid  back  into  the  veins.  It  is  then  thrown  oft"  by  the  kidneys. 
But  you  cannot  trust  to  purgatives  alone  even  to  remove  the 
dropsy,  and  on  the  albuminuria  their  influence  is  to  be  suspected. 
It  is  probably  harmful,  by  increasing  anaemia. 

Of  all  purgatives  the  most  weakening  is  elaterium.  Its  action 
is  a  peculiar  one : — it  causes  an  enormous  flow  of  watery  serum 
from  the  first  mucous  membrane  that  absorbs  it: — if  its  vapor 
be  drawn  up  into  the  nostrils  for  a  short  time,  it  is  a  powerful 
errhine,  and  is  followed  by  the  secretion  of  floods  of  water  from 
the  Schneiderian  membrane;* — if  it  is  dissolved  in  the  oesophagus 
it  causes  such  a  deluge  of  the  gastric  fluids,  that  the  stomach 
cannot  retain  them,  and  they  are  rejected  by  vomiting: — if  it 

*  Used  in  this  fashion  it  was  an  ancient  Greek  remedy  for  jaundice,  and  is 
mentioned  by  Dioscorides.  A  few  years  ago  I  was  informed  by  a  Greeii  pupil 
that  it  is  still  so  administered  in  the  Morea,  and  at  his  request  I  gave  it  to  a 
jaundiced  woman.  It  acted  most  violently,  more  than  a  pint  of  greenish  water 
flowing  from  the  nose,  and  caused  so  much  pain  that  the  patient  said  it  was 
much  worse  than  the  disease;  upon  which,  moreover,  it  had  liltle  if  any  etfect. 
So  I  have  not  repeated  the  experiment. 


460  ALBUMINURIA. 

succeeds  in  passin<;  the  pylorus,  a  choleraic  diarrhoea  gushes 
forth,  stripping  the  membrane  of  its  epithelium  just  like  its 
morbid  prototype.  It  is  therefore  very  uncertain  in  its  opera- 
tion, and  I  am  sure  I  have  seen  patients  not  only  frightened  but 
really  hurt  by  it.  Moreover,  I  have  never  found  benefit  from 
its  use  in  renal  dropsy,  where  jalap  and  bitartrate  of  potash  had 
failed.  So  I  never  give  it ;  but  if  you  are  steadily  purposed  to 
do  so,  use  the  form  of  enema,  for  you  thus  have  a  chance  of 
avoiding  the  vomiting  which  is  so  apt  to  arise. 

To  puncture  the  anasarcous  skin  for  the  sake  of  relieving 
temporarily  the  distention  is  justifiable  where  that  distention  is 
causing  more  harm  than  a  mere  inconvenience,  as  for  instance 
in  the  penis  where  it  impedes  the  passage  of  urine,  or  in  the 
scrotum  and  legs  when  it  threatens  to  crack  or  to  be  frayed  into 
sores.  It  is  better  to  puncture  it  with  a  lancef  to  the  depth  of 
about  a  quarter  of  an  inch  than  with  a  needle :  the  slits  thus 
made  discharge  more  freely  and  continuously,  and  are  less  likely 
to  cause  erysipelas  than  the  smaller  but  more  numerous  needle 
pricks.  I  have  scarcely  ever  found  any  evil  results  to  follow  this 
practice,  and  where  the  skin  and  areolar  tissue  have  been  very 
tense,  I  think  they  have  by  its  means  been  often  preserved  from 
sloughing. 

When  in  dropsy  from  either  albuminuria  or  diseased  heart 
you  are  unfortunate  enough  to  have  a  patient's  skin  slough,  I 
should  recommend  you  to  employ  a  lotion  found  highly  effica- 
cious in  our  wards,  made  of  equal  parts  of  glycerin  and  of 
water  saturated  with  chlorate  of  potash,  and  to  keep  the  surface 
carefully  covered  from  the  air.  The  rapid  restoration  of  vital 
action  to  the  edges  of  the  mortified  tissue  under  the  use  of  these 
means  is  very  remarkable. 


LECTURE   XXXVI. 
ALBUMINURIA. 

Case  of  albuminuria  with  vomiting  after  ague  cured — Case  of 
albuminuria  fatal  by  sudden  pneumonia — Case  of  albuminuria 
fatal  from  epistaxis,  and  loss  of  blood  and  albumen — Com- 
ments. 

{Clinical,  St.  Mary's,  October  31,  1863.) 

Robert  H.,  aged  thirteen,  was  brought  by  his  father  to  the 
hospital  the  first  week  in  September.  They  had  both  landed 
three  days  before  at  Deal  out  of  a  small  schooner  from  Algeria. 
They  had  been  four  weeks  and  a  half  on  the  voyage,  and  during 
the  whole  of  it  had  nothing  to  eat  but  potatoes ;  for  the  beef 
taken  in  store  had  got  putrid.  They  slept  in  the  life  boat,  and 
frequently  got  very  wet.  The  father  was  taken  with  quotidian 
ague  when  about  half  way  over,  and  Robert  had  one  paroxysm 
at  sea,  and  one  after  landing.  For  this  ague  he  was  brought  in 
here,  was  treated  with  quinine,  and  had  no  return.  It  was 
observed,  however,  that  his  spleen  was  enlarged,  and  that  he 
had  some  anasarca  during  this  first  residence  in  the  wards.  On 
the  25th  of  September  he  was  discharged,  and  a  week  after- 
wards the  anasarca  returned  in  his  legs,  and  the  abdomen 
swelled.  He  was  readmitted  on  October  9,  with  anasarca  of 
the  whole  lower  part  of  the  body.  There  was  fluctuation  in  the 
peritoneum  on  percussion,  and  dullness  of  its  lower  portion  on 
both  sides.  No  enlargement  of  the  spleen  could  be  detected. 
The  heart  sounds  were  normal.  The  urine  was  of  a  dusky  brown 
color,  and  very  albuminous. 
30 


462  ALBUMINURIA. 

On  the  10th  he  was  ordered  this  draught — 

^i  Tincturse  ferri  sesquichlo^'idi  lT[xVy 
Potassse  nitratis  gr.  xv 
Misturse  camphor se  Sj, 

ter  die — 
and  a  hot-air  bath  was  administered  every  night. 

Then  occurred  a  symptom  which  is  not  uncommon  in  albumi- 
nuria, namely,  vomiting.  lie  felt  constant  nausea,  and  threw 
up  the  contents  of  the  stomach  several  times  daily.  In  spite 
of  this  the  anasarca  disappeared,  and  the  greater  part  of  the 
fluid  was  absorbed  from  the  peritoneal  sac.  But  yet  it  struck 
me  that  the  medicine  might  have  had  something  to  do  with  the 
sickness.  So  I  left  it  off  once  and  again,  and  both  times  the  in- 
convenience ceased. 

I  did  not  like  foregoing  the  use  of  iron  altogether,  so  I  have 
since  the  24th  kept  him  on  an  ounce  of  mistura  ferri  three 
times  a  day.  That  he  bears  well  and  profits  by.  There  are  no 
signs  of  anasarca  or  ascites  ;  and  what  is  of  more  happy  augury 
still,  the  albumen  no  longer  is  to  be  found  in  the  urine, 
which  is  of  normal  color  and  acidity,  and  1015  in  specific 
•gravity.  He  remains  in  the  hospital  only  because  his  father 
cannot  for  a  few  days  return  from  the  country  to  fetch  him 
home. 

The  only  peculiarity  in  this  case  is  the  vomiting,  which  how- 
ever, as  here,  you  may  often  by  experiment  trace  to  some  un- 
suitable article  in  the  medicine  or  food.  Where  you  cannot 
find  any  cause,  such,  and  it  continues  obstinate,  I  have  found 
alkaline  effervescing  draughts  the  most  effectual  remedy  in  albu- 
minuriacs. 


{St.  Mary's,  Octoher  26,  1863.) 

I  show  you  here  the  kidneys  just  taken  from  the  body  of  an 
adult  who  was  yesterday  brought  into  the  hospital  dead.  He  had 
been  long  delicate,  but  still  able  to  do  a  fair  stroke  of  work. 


ALBUMINURIA.  463 

Two  days  before  lie  had  come  as  a  casualty  patient  to  the  house- 
surgeon,  who  found  him  suffering  from  a  certain  amount  of  pneu- 
monia and  catarrh,  but  was  unable  to  admit  him  as  an  in-patient 
on  account  of  the  fullness  of  the  wards.  The  next  day  he  was 
worse,  but  still  got  up.  On  the  following  morning  a  man  came 
and  said  he  was  very  ill  indeed,  and  obtained  a  promise  of  a  bed 
for  him.     Before  he  got  to  it  he  expired. 

On  examination  it  was  found  that  at  most  a  quarter  (I  should 
have  said  not  so  much)  of  the  right  lung  was  imperfectly  con- 
densed with  recent  inflammation.  The  rest  of  the  pulmonary 
tissue  on  that  side,  and  the  whole  left  lung  was  free  from  con- 
gestion, though  wet.  We  began  to  wonder  at  the  man's  death 
from  so  paltry  a  cause  ;  for  we  are  not  used  to  have  pneumonic 
patients  die,  without  the  pneumonia  being  either  double,  or  at 
least  occupying  the  whole  of  one  lung.  The  heart  too  was  quite 
uninjured. 

But  the  mystery  was  cleared  up  when  we  opened  the  abdomen 
and  found  the  kidneys  I  show  you.  On  tearing  off  their  capsule 
you  see  that  it  adheres  much  closer  than  it  should  do;  and  that 
when  it  is  gone,  the  surface  of  the  organs  is  coarsely  granular, 
instead  of  being  smooth  and  shining.  And  a  section  exliibits  the 
tubercular  and  cortical  structures  much  less  distinct  and  differ- 
ent than  natural.  It  looks  as  if  some  dull  flesh-colored  or  tawny 
stuff  had  been  mixed  up  in  both  of  them.  Truly  there  is  noth- 
ing here  very  conspicuous  to  students  on  the  remoter  benches  of 
the  theater ;  but  still,  if  you  examine  the  parts  in  your  own 
hands,  you  will  see  a  good  deal  abnormal ;  and  if  you  apply 
your  minds  you  will  see  more  still.  You  will  see  that  there  is 
much  here  w^hich  should  not  be,  and  yet  that  the  kidney  is  any- 
thing but  increased  in  size.  There  must,  therefore,  be  a  serious 
loss  or  destruction  of  the  important  secreting  structure  of  the 
viscus.  It  is  in  point  of  fact  not  absolutely  destroyed  or  removed,, 
but  it  is  partially  devitalized  into  a  less  organized  substance, 
which  is  utterly  incapable  of  performing  the  duties  of  separating 
the  urea  from  the  blood,  and  of  retaining  the  albumen  in  the 
blood-vessels.  Hence  the  importance  of  lesions  of  the  kidneys. 
And  hence  also  their  importance  is  in  direct  proportion  to  the 


464  ALBUMINURIA. 

amount  of  secreting  substance  partially  killed  ;  not  at  all  in  pro- 
portion to  their  conspicuousness,  and  to  the  show  they  may  make 
in  the  hands  of  an  artist.  An  abscess,  or  a  stone,  or  an  hydatid, 
may  be  more  capable  of  artistic  development,  but  they  are  by 
no  means  so  important  in  their  influence  on  health  as  a  Bright's 
kidney  so  little  apparent  as  to  be  easily  passed  over  by  a  careless 
dissector. 

I  say  the  patient's  rapid  death  was  explained  by  the  degene- 
ration of  his  kidneys.  But  I  do  not  by  any  means  intend  to 
imply  that  he  died  of  the  renal  disease.  On  the  contrary  I 
bring  this  case  forward  especially  to  show  you  that  it  is  not 
necessarily  a  fatal  lesion.  This  man  had  lived  with  it  probably 
for  years,  and  gained  his  livelihood,  and  might  have  continued 
to  live  and  gain  his  livelihood  for  an  indefinite  period.  It  was 
no  recent  or  sudden  increase  of  the  long-standing  visceral  lesion 
which  caused  death,  but  the  addition  to  it  of  a  slight  pneu- 
monia due  to  external  causes  and  very  far  from  sufficient  in  it- 
self to  kill. 

Both  of  these  facts  are  highly  important  and  suggestive  ;  the 
first  showing  that  a  patient  with  degenerated  kidneys  and  albu- 
minuria may  live,  to  a  certain  extent  enjoy  life,  and  be  an  useful 
member  of  society  ; — and  the  second,  that  if  insignificant  inflam- 
mations are  added,  they  may  very  possibly  prove  rapidly  fatal. 
Both  facts  should  encourage  us  to  spare  no  pains  in  preserving 
the  health  of  our  albuminuriacs,  in  the  well-grounded  hope  that 
such  pains  will  not  be  thrown  away. 


[Clinical,  St.  Mary's,  December  12,  1863.) 

You  have  often  heard  me  say  that  the  amount  of  albumen 
contained  in  the  urine  of  those  affected  by  Bright's  disease,  is  a 
matter  of  no  practical  moment ;  and  1  have  corrected  you  when 
you  have  anticipate/l  evil  results  to  a  patient,  because  the  quan- 
tity exhibited  by  boihng  and  nitric  acid  chanced  to  be  unusually 
large,  or  when  you  have  slurred  over  the  serious  import  of  find- 
ing some  slight  traces  of  its  presence  in  other  instances.     The 


ALBUMINURIA.  465 

fact  is  that  the  loss  of  albumen  is  easily  replaced  by  food.  Con- 
sider that  100  parts  of  meat  contain  from  15  to  20  parts  of  pro- 
teine,  which  are  converted  by  digestion  into  a  soluble  form  of 
albumen  and  pass  directly  into  the  blood  ;  and  consequently 
a  daily  loss  of  10  grammes  of  albumen  may,  if  the  digestion  is 
fair,  be  replaced  by  three  ounces  of  meat  taken  as  food.*  And 
as  a  matter  of  fact  it  usually  is  so  replaced  in  our  hospital 
patients,  whose  anaemia  hardly  ever  increases  while  in  the 
wards. 

Yet  exceptional  cases  do  occur,  to  one  of  which  I  have  to  call 
your  attention  to-day.  Michael  B.,  aged  twenty-two,  of  a 
marked  leucophlegmatic  temperament,  with  pale  blue  eyes  and 
yellow  hair,  a  new  patient  on  November  27,  stated  that  he  had 
continued  well  and  able  to  work  as  an  ostler  till  four  weeks 
before  that  date,  when  he  was  taken  with  vomitings,  rigors,  pros- 
tration, sore  throat,  and  feverishness,  and  was  forced  to  lay  up 
in  his  miserable  lodging  house.  He  could  not  remember  that 
he  or  anybody  else  had  observed  any  eruption  of  the  skin  ;  yet 
I  cannot  but  think  that  this  feverish  attack  was  scarlatina  ;  for 
after  four  days'  illness  his  face  and  legs  began  to  swell,  and 
anasarca  continued  up  to  the  time  of  his  coming  under  treat- 
ment, when  the  ankles,  thighs,  and  abdominal  parietes  all  pitted 
on  pressure.  At  the  same  time  that  he  became  dropsical  he 
began  to  sufier  from  pain  in  the  loins,  and  he  observed  his  urine 
to  be  frequently  bloody — indeed  more  often  bloody  than  not.  He 
had  suffered  also  from  bleeding  at  the  nose,  and  from  vomiting. 
His  respiration  during  the  previous  week  had  become  short  and 
diflBcult  when  he  lay  down  in  bed,  so  that  he  had  to  sit  up,  and 
snorted  and  snored  a  great  deal  in  breathing,  often  also  gasping 
for  breath  and  sighing. 

He  was  sent  to  bed  and  cupped  to  eight  ounces  on  the  lions. 
Sesquichloride  of  iron  and  tincture  of  digitalis  were  at  the  same 
time  prescribed  for  him.  This  treatment  was  commenced  imme- 
diately, and  perhaps  it  was  in  consequence  of  it  that  we  never 
saw  the  urine  bloody,  and  that  he  had  no  more  pain  in  the  back. 
At  all  events  such  was  the  fact.     But  though  there  was  no  blood 

*  Vogel  on  "  Quantitative  tests  of  albumen." 


466  ALBUMINURIA. 

ill  it  the  urine  contained  an  unusually  enormous  quantity  of 
albumen,  some  specimens  coagulating  by  heat  nearly  into  a 
gelatinous  mass.  It  was  copious,  light-colored,  and  of  a  specific 
gravity  alw&ys  below  1*01.5.  A  drop  of  blood  drawn  from  a 
needle  prick  of  the  finger  was  very  pale,  and  placed  under  the 
microscope  exhibited  a  deficient  number  of  red  disks  in  propor- 
tion to  the  white  globules,  which  latter  were  in  comparative  ex- 
cess ;  and  there  was  a  considerable  abnormal  quantity  of  the 
fine  granules  in  the  serum.  Many  of  the  red  disks  had  also  fine 
granular  specks  in  them  as  if  degenerating,  and  quickly  became 
crenated  at  the  edges ;  they  however  formed  into  rolls  in  the 
natural  fashion. 

On  the  28th  he  had  some  epistaxis,  and  several  times  threw 
up  his  food.  In  it  there  were  some  masses  of  mucus  stained 
with  blood,  but  whether  these  came  from  the  stomach  itself  or 
from  the  nose  could  not  be  rightly  determined. 

By  the  2d  of  December  the  anasarca  had  quite  disappeared. 
But  the  patient  still  breathed  noisily,  irregularly,  and  quickly, 
and  gasped  often  like  a  person  exhausted  by  loss  of  blood.  The 
uvula  was  much  relaxed,  hanging  down  on  the  top  of  the  glottis, 
and  he  coughed  frequently  and  spoke  in  a  whisper. 

On  the  4th  he  got  up  and'  moved  about  the  ward  a  little,  but 
was  terribly  exhausted  by  the  exertion. 

On  the  5th  the  epistaxis  had  become  more  frequent,  but  was 
very  small  in  quantity  at  a  time.  It  little  more  than  just  stained 
the  handkerchief,  so  pale  was  his  blood.  The  enormous  quan- 
tity of  albumen  lost  by  the  kidneys  was  unabated,  but  he  kept 
down  more  food.  On  account  of  the  epistaxis  I  ordered  him 
twenty  grains  of  gallic  acid  three  times  a  day. 

On  the  6th  I  found  him  sinking.  The  countenance  was  ex- 
cessively anxious,  he  was  throwing  his  arms  about  in  an  agitated 
manner,  gasping  and  sighing  and  complaining  of  pain  all  over, 
especially  at  the  epigastrium.  His  tongue  got  dry  and  yellow, 
sordes  collected  on  the  teeth.  But  his  mind  was  perfectly  clear, 
and  seems  to  have  remained  so  till  his  death  next  day. 

The  case  will  of  course  be  entered  in  the  register  as  one  of 
"dropsy,"  for  with  that  disease  he  was  received  into  the  hos- 


ALBUMINURIA.  467 

pital ;  but  yet  he  did  not  die  of  dropsy,  either  in  the  form  of 
anasarca,  hydrothorax,  oedema  pulmonura,  effusion  on  the  brain, 
or  of  any  of  the  kinds  of  local  congestion  which  conclude  nearly 
every  renal  degeneration.  Altogether,  his  end  resembled  that 
of  one  killed  by  long  hemorrhage.  And  in  truth  that  may  be 
said  to  have  been  the  manner  of  it.  For  though  latterly  there 
was  scarce  any  appearance  of  red  blood  in  what  he  lost,  yet  what 
he  lost  was  a  part  of  the  blood  next  in  importance  to  the  red 
constituents.  While  at  the  same  time  the  state  of  his  stomach 
prevented  the  drain  of  albumen  passing  away  from  being  re- 
placed. 

The  case  is  very  different  from  one  of  uraemic  poisoning;  it  is 
the  albuminuria,  the  loss  of  constructive  material,  and  not  the 
ur{3emia  or  retention  of  injurious  material,  which  has  killed  the 
patient.  There  was  none  of  the  coma,  or  merciful  overclouding 
of  mental  perception,  which  is  the  usual  end  in  Bright's  disease; 
but  on  the  contrary  extreme  sensitiveness  and  agitation.  I  re- 
joice to  think  that  such  a  termination  is  rare,  for  it  is  most  pain- 
ful to  witness. 

But  for  all  that  there  is  no  doubt  of  the  kidneys  being  exten- 
sively disorganized  by  some  form  of  Bright's  disease,  and  con- 
sidering his  age  and  the  rapidity  of  the  fjital  result  I  should 
rather  expect  to  find  at  the  post-mortem  examination  you  are 
going  to  see  to-day,  a  specimen  of  the  yellow  smooth  kidney. 
How  long  he  has  had  it  none  can  tell;  but  it  cannot  have  been 
long,  for  he  was  not  injured  by  it  till  the  scarlet  fever  (as  I  sup- 
pose) added  its  renal  congestive  influence  to  a  pre-existent  lesion. 

In  describing  this  patient's  appearance  I  drew  your  attention 
to  his  leucophlegmatic  crasis.  Now,  I  am  far  from  wishing  you 
to  put  faith  in  all  the  vagaries  built  upon  the  doctrine  of  tem- 
peraments, as  you  know  well  from  my  systematic  course  on  the 
practice  of  medicine.  Yet  I  cannot  shut  my  eyes  to  the  fact, 
that  there  are  certain  forms  of  internal  constitution,  which,  when 
they  exist  in  a  marked  degree,  do  declare  themselves  by  the  ex- 
ternal features,  and  that  it  is  not  entirely  devoid  of  practical 
utility  to  take  heed  of  them  in  regulating  our  treatment.  Of 
these  classes  of  constitutions  one  of  the  most  important  in  re- 


468  ALBUMINURIA. 

spcct  of  our  practice  is  the  leucophlegmatic.  This  is  not  the 
place  or  time  to  paint  its  peculiarities,  which  has  been  done  so 
often  by  more  graphic  artists  than  I  can  hope  to  be.  But  all 
agree  in  contrasting  it  with  the  sanguine,  and  making,  in  short, 
these  two  temperaments  antithetical  to  one  another  as  to  all 
their  habitual  phenomena.  Now,  it  has  always  struck  me,  that 
the  most  important  antithesis  between  them  is  one  not  usually 
brought  forward,  or  at  least  only  indirectly  alluded  to.  I  mean 
the  relation  which  they  bear  to  degenerative  disease.  In  the 
sanguine  temperament  febrile  disease  is  short,  violent,  and  soon 
ended — "cito  mors  venit,  aut  victoria  Iseta" — while  degenerative 
disease  is  slow  in  progress,  slightly  marked  in  its  phenomena, 
and  little  affected  for  better  or  for  worse  by  remedies.  In  the 
leucophlegmatic  temperament  febrile  disease  is  sluggish  in  pro- 
gress, and  imperfectly  marked  in  its  characters;  while  degene- 
rative disease  is  extremely  rapid,  strongly  marked,  and  either 
quickly  fatal  or  freely  amenable  to  remedies.  It  has  been,  as 
you  have  witnessed,  rapidly  fatal  in  the  patient  who  is  the  text 
of  this  lecture ;  but  I  have  often  -pointed  it  out  to  you  checked 
with  equal  rapidity  in  more  fortunate  leucophlegmatic  subjects. 
The  observation,  therefore,  of  the  temperament,  affects  both  our 
prognosis  and  our  treatment. 

[As  the  autopsy  took  place  after  lecture  I  append  an  account 
of  it. 

Extract  from  Record  of  post  examination  of  Micliael  B.,  by 
Mr«  Nayler,  Curator  to  St.  Mary's  Hospital  Museum. 

'•'-  Examination  five  days  after  death. — The  kidneys  were  of 
small  size,  weighing  respectively  only  one  and  a  half  and  two 
ounces ;  they  were  studded  with  small  cysts  varying  from  a 
millet  seed  to  a  pea  in  diameter.  They  were  pale  and  mottled 
externally  and  the  capsule  was  readily  detached.  The  lungs 
were  very  pale,  but  otherwise  healthy  and  expansible.  There 
was  a  good  deal  of  blood-stained  fluid  in  both  pleura." 

The  blood  stain  of  the  fluid,  and  some  other  phenomena  not 
necessary  to  notice  here,  were  probably  caused  by  the  length  of 
time  which  was  unavoidably  allowed  to  elapse  between  the  death 


ALBUMINURIA.  469 

and  the  autopsy.  The  appearance  of  the  kidneys  was  not  quite 
what  was  to  have  been  looked  for  from  the  symptoms.  The 
short  time  that  the  patient  had  been  ill,  and  the  acute  nature  of 
the  illness,  would  not  have  led  to  the  expectation  of  seeing  them 
small  and  shrunken.  This  may  serve  as  a  warning  to  clinical 
lecturers  not  to  be  so  over-precise  in  their  predictions  as  I  was 
in  the  last  page.] 


LECTURE    XXXVII. 

ASCITES. 

Part  I. —  Case  of  ascites  fro7n  hepatic  degeneration,  tvhich  had 
relapsed  several  times  after  tapping,  prevented  from  returning 
hy  the  use  of  iron — Cause  of  the  disease  irremovable,  yet  the 
disease  capable  of  cure — Pathology  of  ascites,  and  connection 
of  the  treatment  with  that  pathology. 

Part  II. — Case  of  ascites  from  renal  degeneration  treated  with 
iro7i  and  cured,  though  the  albuminuria  remains  as  before — 
Contrast  of  this  with  two  cases  of  albuminuria  from  a  reme- 
diable cause. 

(Part  I. — Clinical,  St.  Mary' s,  January  16,  1863.) 

William  S.,  aged  thirty-four,  though  lie  himself  denies  having 
lived  an  intemperate  life,  receives  a  diflferent  character  from  a 
brother,  who  tells  us  that  William  has,  at  various  periods,  drank 
hard,  and  that  even  when  not  indulging  in  drunkenness,  has  been 
in  the  habit  of  taking  drams  and  beer  between  meals,  and  in 
consequence  has  kept  himself  in  a  low  position  in  the  social 
scale.  The  patient  says  that  the  only  illness  different  from  the 
present  he  has  ever  suffered  from  is  rheumatism  without  swell- 
ing (either  chronic  rheumatism  or  rheumatic  gout),  with  which 
he  was  laid  up  twelve  years  ago.  Two  years  since  friends  noticed 
that  his  complexion  became  jaundiced,  and  a  year  after  that  the 
abdomen  swelled,  for  which  he  was  in  St.  George's  Hospital  five 
weeks,  and  went  out  somewhat  relieved.  He  then  drank  green 
broom  tea,  and  got  much  smaller  in  consequence.  In  August, 
however,  the  belly  swelled  again  much  larger  than  before,  and 
at  the  end  of  October  was  so  large  that  his  surgeon  tapped  him, 
and  drew  off  a  large  quantity  of  fluid.     Immediately  afterwards 


ASCITES.  471 

it  swelled  again  bigger  than  ever,  and  on  admission  at  St.  Mary's, 
November  18,  1862,  he  was  so  ascitic  that  he  could  not  stand; 
the  breathing  was  much  interfered  with,  and  there  was  some 
anasarca  of  the  legs.  Tapping  was  accordingly  again  resorted 
to,  and  the  quantity  drawn  away  amounted  to  a  few  ounces  over 
four  gallons  of  clear  fluid.  At  the  same  time,  as  the  urine  did 
not  exceed  about  half  a  pint  in  the  twenty-four  hours,  he  was 
ordered  the  following  diuretics: — 

I^  Pil.  hydrargyri, 
Scillse  pulvei'is, 
Digitalis  pulveris,  aa  gr.  ij, 

omni  nocte  et  mane. 
Infusi  seoparii  5iij, 
jSps.  oetheris  nitrici  ITjxx, 
j^theris  clilorici  IT^x, 

quartd  qudque  liord. 

But  in  six  days  he  was  quite  as  full  of  water  again  as  ever, 
the  abdomen  was  distended  and  painful,  there  was  pain  in  taking 
food  into  the  stomach,  and  it  was  often  vomited  up  again.  The 
urine  too  remained  excessively  scanty,  depositing  a  copious 
orange- colored  precipitate.  Elaterium  was  then  given  in  ad- 
dition, but  with  no  beneficial  effect  either  when  administered  in 
enema  or  by  the  mouth.  He  took  it  for  ten  days,  and  then  was 
seen  to  be  growing  gradually  larger  and  more  incapable  of 
motion.  On  December  10  you  may  see  that  all  his  former 
remedies  were  left  off,  and  he  was  treated  with  the  following 
draught  three  times  a  day : 

Tiiicturse  ferri  sesquichloridi  ll|xx, 
Potassse  nitratis  gr.  xv, 
Histurse  camphor se  Sj- 

He  very  soon  began  to  improve.  His  appetite  returned,  and 
on  the  25th  he  was  able  to  get  up,  dress  himself,  and  be  about 
in  the  ward.  His  abdomen  ceased  to  increase,  indeed  was  an 
inch  or  so  less  in  girth  than  before   the  change  of  medicine. 


472  ASCITES. 

But  here  it  was  stationary,  so  on  the  31st  I  persuaded  him,  with 
some  trouble,  to  be  tapped  again:  nineteen  pints  of  fluid  were 
drawn  off,  when  it  ceased  to  flow,  and  some  was  apparently  left 
in  the  peritoneum.  Since  then  he  has  not  again  swelled,  the 
bowels  are  regular  and  the  appetite  good.  A  fortnight  after 
the  tapping  I  find  the  clinical  clerk  has  noted  that  he  has  got 
smaller  in  girth,  and  that  he  makes  a  pint  of  urine  every  night 
and  a  good  deal  during  the  day.  This  increase  in  the  action  of 
the  kidneys  has  been  gradual  and  did  not  immediately  follow 
the  last  tapping.  The  patient  is  so  impressed  with  the  source 
of  his  disorder  being  traceable  to  alcoholic  drinks,  that  he  asked 
to  have  an  egg  daily  in  place  of  some  ale  which  had  been  allowed 
him. 

This  case  is  a  typical  instance  of  the  very  common  history  of 
continual  indulgence  in  depraved  tastes.  The  constant  presence 
of  alcohol  in  the  blood  obstructs  the  necessary  renewal  of  the 
fibrous  capsule  of  the  liver;  contraction  of  the  degenerated 
tissue  ensues;  the  portal  blood  cannot  pass  through  the  viscus, 
to  get  rid  of  its  efiete  particles  or  to  bear  the  nutriment  to  the 
general  circulation;  the  natural  halitus  of  the  peritoneal  sac 
cannot  be  reabsorbed,  and  therefore  accumulates  to  form  an 
ascitic  (or,  as  the  Greek  word  means,  an  "ensacked")  collection 
of  serum.  With  this  fluid  is  mixed  also  the  albuminous  serum 
and  fibrous  serum  which  exudes  from  the  obstructed  capillaries, 
and  often  these  capillaries  rupture  and  blood  corpuscles  are 
found  in  the  dropsical  fluid. 

Observe  that  in  such  cases  as  these,  of  which  William  S.  is  a 
strongly  marked  example,  we  have  permanently  fixed  in  the  body 
a  constant  source  of  disease,  a  deformity  of  an  important  organ 
which  is  absolutely  incapable  of  being  replaced.  The  patient's 
liver  is  indubitably  the  cause  of  disease:  if  we  could  see  it  we 
should  probably  find  it  puckered  up  and  scarred  with  hard  con- 
tracting fibrous  tissue,  compressing  and  causing  atrophy  of  the 
secreting  structure.  The  majority  of  the  hepatic  cells  are  proba- 
bly dead  and  converted  into  or  filled  with  fat;  and  there  is  not 
room  for  new  cells  to  grow.  You  can  no  more  cure  this,  than 
you  can  cure  the  hard  useless  scar  of  a  wound.     It  is  not  your 


ASCITES.  473 

business  to  cure  it,  for  it  is  not  the  disease.  The  disease  is  its 
consequences,  the  ascites,  the  anasarca,  the  diminished  urinary 
secretion,  the  jaundice,  the  anjemia,  the  general  discomfort  under 
which  the  man  labors.  These  are  capable  of  very  decided  al- 
leviation and  often  of  cure.  You  may  look  at  the  matter  in 
this  light — you  have  a  patient  whose  body  is  deformed  by  a 
deficiency  of  liver ;  and  as  you  are  unable  to  give  him  back  a 
liver,  your  aim  must  be  to  give  him  back  those  functions  and 
those  constituents  of  the  body  wliich  the  wanting  organ  has 
ceased  to  supply. 

Remark  what  happened  when  the  ascites  was  treated  merely 
as  a  foreign  body,  as  a  thorn  in  the  flesh  to  be  plucked  out. 
The  quantity  and  weight  of  the  fluid  was  a  very  painful  burden 
to  him;  it  entirely  prevented  his  getttng  up,  pressed  on  the 
stomach,  produced  vomiting,  and  seemed  to  the  patient  to  leave 
no  room  for  his  meals.  So  there  was  a  reason  for  its  removal 
by  tapping.  But  he  immediately  swelled  again  as  large  as 
ever,  if  not  larger,  on  the  first  two  applications  of  this  process. 
And  during  this  period  the  most  powerful  diuretics  were  vainly 
directed  to  increase  the  action  of  the  kidneys.  He  himself  felt 
strongly  the  failure,  and  declared  that  it  should  never  be  done 
again. 

See,  however,  the  efi'ect  of  a  three  weeks'  course  of  iron.  He 
recovered  strength  so  far  as  to  remain  sitting  up  in  the  ward  a 
great  part  of  the  day;  although  the  abdomen  was  as  large  as  at 
first  and  much  impeded  motion,  his  muscular  power  enabled  him 
to  walk  about;  he  gained  flesh  and  some  color  in  his  cheeks. 
Then  was  the  time  for  tapping  to  be  efi'ectual,  and  with  some 
trouble  he  was  persuaded  to  retract  his  resolve  and  to  submit  a 
third  time  to  what  he  justly  enough  urged  had  failed  before.  A 
considerable  portion  of  the  fluid  was  drawn  ofi",  and  that  amount 
which  was  removed  has  not  again  accumulated.  He  continues 
to  get  smaller  in  girth  daily,  and  I  hope  in  two  or  three  weeks 
will  be  fit  to  leave  the  hospital. 

The  rationale  of  his  improved  condition  is  that  the  iron  has 
restored  the  blood  to  its  natural  state,  and  thus  supplied  to  the 
tissues   that  which   is  the   final  end   of  nearly  all   our   care — 


474  ASCITES. 

namely,  healthy  nutriment.  Without  this  any  treatment  would 
be  utterly  useless;  with  it  you  see  a  rough  treatment,  namely, 
tapping,  which  had  been  unsuccessful  once  and  again  under 
previous  circumstances,  has  now  led  to  a  happy  result.  Can 
we  refuse  to  recognize  this  as  true  restoration,  as  real  cure? 

I  am  sorry  to  say  it  has  been  impossible  entirely  to  keep  his 
old  habitual  poison  from  him.  His  spirits  and  nervous  system 
generally  got  so  low  that  it  was  necessary  to  allow  him  some  gin 
daily.  I  am  gradually  diminishing  his  allowance,  but  I  fear 
that  when  he  gets  out  of  our  sight  he  will  not  be  able  to  refrain. 
This  of  course  must  keep  up,  even  if  it  does  not  increase,  the 
degeneration  of  the  hepatic  tissues,  and  very  slight  accidents  will 
readily  bring  back  his  dropsy.  But  so  far  as  he  is  restorable,  I 
think  you  have  learnt  the  way  to  restore  him. 

The  pathology  of  ascites  I  presume  to  be  this — from  obstruc- 
tion of  the  liver,  either  temporary,  of  which  you  have  one  ex- 
ample in  diseases  of  the  heart,  or  permanent,  as  in  degenera- 
tion of  the  hepatic  tissue  itself,  or  in  compression  of  it  by 
malignant  tumors  and  the  like,  the  passage  of  blood  through  it 
is  hindered.  This  imperfectly  vitalized  blood  insuflSciently 
nourishes  the  vessels  of  the  peritoneum,  which  consequently 
become  inelastic  and  more  ready,  even  than  they  should  be,  to 
part  with  their  watery  contents  by  exosmosis.  At  the  same  time 
the  sluggish  movement  of  the  circulating  fluid  retards  absorption, 
according  to  the  well-known  law  that,  in  the  case  of  a  fluid  set  in 
motion,  osmosis  is  rapid  in  a  direct  ratio  to  that  motion.  Thus 
you  have  a  double  reason  for  the  collection  of  the  fluid,  increased 
exports  from  the  blood  and  diminished  imports. 

Rational  medication  makes  its  chief  aim  the  remedying,  as 
far  as  remediable,  such  a  state  of  things.  It  aims  at  restoring 
strength  and  elasticity  to  the  abdominal  capillaries,  at  quicken- 
ing and  vitalizing  the  circulating  blood,  and  thus  renewing 
absorption  to  its  normal  activity.  Normal  activity !  no  slight 
thing  is  this  we  are  speaking  of:  remember  Dr.  Richardson's 
experiment  by  which  he  showed  that  fluid  equal  to  at  least  one- 
sixth  of  an  animal's  whole  weight  may  be  absorbed  by  the  peri- 


ASCITES.  475 

toneum  in  twelve  liours:*  and  then  consider  that  if  a  man's 
peritoneum  can  work  at  an  equal  rate  (as  I  dare  say  it  can)  he 
will  be  able  to  dispose  of  at  least  a  couple  of  gallons  in  the  same 
time.  So  that  if  you  can  secure  anything  like  a  normal  activity, 
you  will  soon  do  away  with  the  ascites.  Look  upon  it  as  a  col- 
lection dependent  on  deficient  vitality,  not  as  an  eflFusion  depend- 
ent on  some  imaginary  increased  action,  and  your  treatment  has 
a  better  chance  of  being  rational  and  successful. 

You  will  perhaps  say  that  I  was  inconsistent  in  tiot  trusting 
wholly  to  the  iron,  and  that  tapping  ought  to  have  been  needless. 
The  fact  is  that,  after  long  soaking  with  the  ascitic  fluid,  the 
tissues  are  so  saturated  with  it  that  they  can  return  to  their 
allegiance  but  very  slowly ;  and  that  the  process  is  much  hast- 
ened by  removing  the  already  collected  serum.  After  the 
operation  indeed  you  may  give  the  iron  with  safe  confidence, 
and  your  confidence  will  often  be  justified  by  a  similar  success 
to  that  which  has  attended  this  case. 

I  hope  soon  to  send  this  patient  to  the  Convalescent  Hospital. 

(Part  ll.—CUnical,  St.  Martjs,  July  25,  1863.) 

Dennis  S.  has  been  under  your  observation  since  June  12. 
His  age  is  sixty,  and  his  employment  that  of  a  costermonger. 
I  have  no  reason  to  doubt  his  statement  that  he  has  been  always 
a  sober  and  temperate  man,  but  of  course  in  his  trade  he  has 
been  a  good  deal  exposed  to  inclement  weather.  Two  years 
ago  he  was  knocked  down  by  a  cart  which  passed  over  his  loins; 
and  during:  the  illness  which  followed  there  was  blood  in  his 
urine,  and  he  was  told  by  a  physician  who  attended  him  that 
the  kidneys  Avere  injured.  After  that  he  recovered  health,  and 
was  well  till  last  March,  when  he  felt  out  of  sorts,  and  had  cold 
skin  and  frequent  shiverings.  Soon  the  legs  began  to  swell,  and 
he  had  looseness  of  bowels,  amounting  sometimes  to  diarrhoea, 
after  eating.  He  had  also  much  cough,  accompanied  by  thin 
mucous  expectoration.  In  May  the  belly  began  to  swell,  and 
the  complexion  became  of  a  pale  faded-leaf  color. 

*  See  the  previous  Lecture  on  Hydrothorax,  page  201. 


476  ASCITES. 

When  first  I  saw  him  in  bed  there  was  very  considerable 
anasarca  of  the  legs  and  ascites  of  the  abdomen.  But  a  couple 
of  days'  confinement  to  bed  took  away  all  the  swelling  of  the 
lower  extremities,  leaving  the  ascites  as  the  marked  feature  of 
the  case.  He  measured  forty  inches  round  at  the  level  of  the 
navel,  and  the  dullness  on  percussion  caused  by  the  fluid  rose  to 
within  four  inches  of  the  mesian  line.  His  urine  was  light- 
colored,  copious,  of  specific  gravity  from  I'OIO  to  1*015,  and 
very  albuminous.  There  could  be  found  in  it  sometimes  granu- 
lar, sometimes  smooth  casts  of  the  tubes. 

He  was  ordered  irjxx  of  the  tincture  of  the  sesquichloride  of 
iron  four  times  a  day,  and  had  hot-air  baths  at  night.  I  have 
omitted  to  note  when  the  baths  were  left  off,  but  I  think  he  had 
only  five  or  six ;  as  they  were  ordered  in  consequence  of  the 
anasarca. 

On  June  24  he  measured  thirty-eight  inches  round,  and  on 
the  26th  thirty-seven  inches. 

I  must  remark  that  this  measurement  did  not  fairly  represent 
the  total  diminution  of  fluid.  For  the  abdomen  was  very  reso- 
nant in  places  where  it  had  previously  been  dull.  In  fact  the 
vacant  space  left  by  the  serum  absorbed  from  the  cavity  of  the 
peritoneum  had  been  occupied  by  ilia  and  colon  blown  up  with 
wind.  Do  not  forget  this  in  your  estimate  of  the  decrease  of 
ascites — the  intestinal  walls,  from  being  so  long  soaked  in  half- 
dead  serum,  lose  their  contractility  and  become  distended  with 
flatus;  and  thus  the  mere  circumference  does  not  show  how 
much  fluid  is  in  the  sac.  You  must  correct  your  reckoning  by 
the  extent  of  dullness. 

To  replace  the  lost  contractility  I  added  /q  of  a  grain  of 
hydrochlorate  of  strychnia  to  each  dose  of  iron.  I  find  nothing 
so  powerful  as  this  to  restore  that  deficient  muscular  force  which 
is  shown  in  flatus  of  the  ilia.  And  while  I  am  on  the  subject 
I  would  give  you  a  hint  that  you  have  no  need  to  be  alarmed  at 
a  few  twitches  or  cramps  or  at  a  slight  stifl'ness  of  the  jaw 
arising  in  patients  who  are  taking  it ;  the  healthy  muscles,  the 
muscles  you  do  not  care  to  aff'ect,  are  aff'ected  first  in  many 
cases ;  should  this  happen,  all  you  have  to  do  is  to  leave  off  the 


ASCITES.  477 

medicine  for  a  day,  and  then  begin  it  again  in  somewhat  smaller 
doses.  Do  not  leave  it  off  altogether.  I  have  never  seen  the 
slightest  real  harm  done  by  strychnine,  though  it  is  a  favorite 
remedy  of  mine.  The  notion  of  its  "accumulating"  in  the 
body  seems  to  be  a  fallacy  derived  from  its  occasionally  acting 
more  visibly  as  the  patient  nears  health. 

On  June  26  his  girth  was  37  inches,  and  continued  steadily 
to  decrease ;  so  that  on  July  15  (if  not  before)  his  belly  was 
soft  and  lax,  and  of  its  natural  size,  as  tested  by  the  waistband 
of  his  former  trousers,  namely  32  inches.  This  represents  the 
absorption  of  from  three  pints  to  half  a  gallon  of  serum. 

He  left  the  hospital  yesterday  in  sufficiently  good  case  to  re- 
sume his  trade,  at  least  for  the  summer.  For  along  with  the 
anasarca  and  ascites,  the  cough,  arising  from  a  dropsical  state 
of  the  pulmonary  tissue,  has  got  well.  But  the  urine  still  re- 
mains albuminous. 

The  last  example  of  ascites  upon  which  I  gave  a  clinical  lec- 
ture,* was  one  arising  from  degenerated  liver.  On  William  S.'s 
return  from  the  Convalescent  Hospital  at  Walton  six  weeks  after 
he  left  St.  Mary's,  he  professed  to  be  quite  well,  and  to  be  con- 
vinced of  the  importance  of  temperance  and  iron  to  keep  him 
so.     I  hope  he  is  sincere. 

The  present  example  arises  principally  from  degenerated 
kidneys,  of  which  the  diseased  urine  (albuminuria)  affords  evi- 
dence. Degeneration  of  these  organs  is  usually  due  to  exposure 
to  weather,  and  is  no  proof  at  all  of  indulgence  in  alcohol.  I 
am  disposed  fully  to  credit  this  man's  statement  that  he  has 
lived  temperately. 

Whether  there  is  not  also  some  slight  degeneration  of  the 
hepatic  substance,  I  cannot  say.  Very  possibly  it  is  so,  to  judge 
bytthe  ascites  being  such  a  marked  feature  in  the  case.  For 
where  the  kidneys  alone  are  at  fault,  anasarca  is  usually  the 
prominent  disease  :  but  where  some  other  organ  fails  also  in  a 
minor  degree,  such  as  the  lungs,  or  the  brain,  or  the  liver  for 
instance,  then  the  joint  influence  of  the  tAvo  deficiencies  appears 

*  Viz.,  that  of  January  16,  1863,  which  begins  this  Lecture. 
31 


478  ASCITES. 

in  that  quarter,  in  the  shape  of  hydrothorax,  or  apoplexy,  or  (as 
here)  of  ascites. 

Whatever  the  anatomical  cause  of  the  disease  may  be,  it  has 
been  cured  by  iron,  rest,  good  food, 'and  strychnine.  We  may 
take  for  granted  that  the  faulty  organs  are  as  degenerated  as 
ever  ;  but  Dennis  S.  may  be  freed  from  disease,  and  may  keep 
free  from  disease  if  he  can  get  the  -wherewithal,  and  possibly 
attain  his  threescore  years  and  ten. 

I  want  you  to  understand  that  what  we  have  to  treat  is  the 
ascites  or  the  anasarca,  as  the  case  may  be.  Without  the  help 
of,  or  with  the  very  imperfect  help  of,  the  liver  and  the  kidneys, 
we  have  got  to  restore  to  the  blood-vessels  that  defective  elasti- 
city, and  to  the  blood  that  defective  composition,  for  want  of 
which  the  balance  of  endosmosis  and  exosmosis  is  reversed.  I 
have  already  told  you  how  iron  does  this. 

In  our  profession  we  have  often  thus  to  cure  the  wound  with 
the  bullet  still  in,  to  relieve  the  burn  with  the  fire  still  scorch- 
ing it ;  for  the  bullet  and  the  fire  are  parts  of  the  body  itself 
and  cannot  be  extracted. 

But  it  is  not  always  so  in  cases  of  dropsy  from  albuminuria. 
You  have  two  proofs  to  the  contrary,  which  have  been  close 
neighbors  to  the  ascitic  patient  in  the  same  Avard — two  little 
boys,  of  six  years  old  each,  who  were  admitted  with  dropsy  and 
albuminuria,  ^the  one  (Michael  K.)  on  July  3,  and  the  other 
(Walter  P.)  on  July  7.  In  both  of  them  not  only  has  the  dropsy 
sot  well,  but  the  urine  has  ceased  to  be  albuminous. 

Why  ?  because  it  arose  from  a  temporary  not  a  permanent 
cause,  from  a  congestion  of  the  renal  tissue  which  can  pass 
away.  In  one  lad's  case  there  was  a  clear  account  of  scarlatina, 
for  some  of  our  house-surgeons  had  seen  it ;  and,  though  the 
mother  of  the  other  denied  that  she  had  seen  any  cutaneous 
eruption,  yet  she  admitted  that  she  was  always  out  charing  all 
day ;  and  she  brought  her  child  here  in  such  a  filthy  lousy 
plight  that  I  do  not  think  she  could  have  looked  much  at  its 
skin.  There  was  an  abscess  also  in  one  of  the  tonsils,  which 
combined  with  the  dusky  color  of  the  urine  to  assure  me  that 
this  also  was  an  instance  of  scarlatinous  dropsy,  and  encouraged 
me  to  give  a  favorable  prognosis. 


ASCITES.  479 

I  said  the  dusky  "  color  of  the  urine"  encouraged  me.  In 
fact,  that  showed  me  that  at  least  a  part  of  the  obstruction  of 
the  renal  tissue  was  due  to  fluid  blood,  which  may  be  expected 
to  move  on  ;  and  not,  as  in  the  old  man's  case,  to  a  degenerate 
solid,  which  is  an  immovable  impediment.  You  may  remember 
the  anatomy  school  porter  showing  some  of  us  a  few  weeks  ago 
a  kidney  which  he  had  taken  from  a  patient,  whose  death  he  be- 
lieved arose  from  scarlatina.  At  all  events,  what  he  showed  us 
presented  in  a  marked  degree  the  character  of  a  scarlatinous 
kidney.  The  medullary  cones  were  clear  and  pale  towards  their 
apices,  indeed,  paler  than  usual ;  but  their  bases  had  a  dark 
blood-red  halo  of  intense  congestion,  rendered  more  conspicuous 
by  the  natural  color  of  the  rest  of  the  cortical  substance.  They 
looked  like  flesh-colored  fans,  whose  broad  ends  had  been 
soaked  in  red  wine  lees.  Such  a  state  of  congestion  as  this  is 
perfectly  curable  ;  and  without  there  should  be  any  evidence  to 
the  contrary,  any  previous  illness  or  the  like,  this  is  the  state 
you  should  assume  to  exist  in  albuminuria  after  or  during  scar- 
latina. This  is  the  state  which  you  see  me  endeavour  to  pre- 
vent in  scarlatina,  by  keeping  the  patients  from  cold  chills  (after 
the  skin  has  been  cooled  by  sponging),  and  by  giving  them  a 
dose  of  castor  oil  every  morning.  A  plan  which  will  usually 
prevent  scarlatinous  dropsy,  but  of  course  will  not  cure  it  when 
once  began. 

Both  of  these  children  had  the  same  treatment  as  the  old  man, 
hot-air  baths  and  iron.  Walter  P.,  in  whom  the  scarlatina  was 
the  most  certain  and  most  recent,  and  who  seemed  to  experience 
some  uncomfortable  feeling  in  his  back  which  he  was  too  young 
to  describe,  had  also  four  leeches  and  a  poultice  applied  to  the 
loins  ;  the  reason  for  which  I  have  sufficiently  pointed  at  by  my 
sketch  of  the  morbid  anatomy  of  the  disease.  The  happy  result 
which  has  followed  is  that  which  usually  rewards  our  efforts  in 
cases  of  scarlatinous  dropsy,  if  no  previous  degeneration  has  ex- 
isted. 


LECTURE    XXXVIII. 
DIABETES. 

Case  and  treatme.'nt — Pathology  of  diabetes — Saccharine  diet 
injurious — Test  of  treatment  is  gaiji  of  flesh — Patient  to  be 
made  carnivorous — Sugar  formed  from  flesh  diet,  or  from 
hepatic  tissue,  but  from  dead  not  live  tissue — Hotv  far  a  strict 
dietary  should  be  enforced — Ojnum —  Cinchoyia — Iron — Iodide 
of  'potassium — Gratification  of  thirst. 

[ainical,  St.  Marys,  July  19,  1862.) 

William  S.,  aged  twenty-two,  a  thin,  whiskerless  and  young- 
looking  farm-laborer,  has  suffered  for  full  two  years  ailments  of 
various  kinds  which  are  usually  held  to  be  symptomatic  of  dia- 
betes. He  has  been  unequal  to  hard  labor,  felt  always  thirsty 
and  usually  hungry,  and  voided  large  quantities  of  urine.  For 
a  year  he  has  been  unable  to  work  at  all,  and  on  that  account 
came  into  St.  Mary's,  May  31,  at  which  time  the  above  symp- 
toms were  noted.  The  chest  was  found  healthy,  the  pulse  regu- 
lar. The  bowels  acted  daily.  The  skin  was  naturally  moist, 
and  he  stated  that  at  night  he  often  perspired.  Sleep  was  sound, 
except  when  he  was  awakened  by  the  bladder  getting  full  of 
urine.  His  weight  was  6  st.  11|  lbs.  He  remained  in  hospital 
five  weeks,  during  which  period  the  variations  in  the  urinary 
symptoms,  and  of  weight,  and  the  alterations  in  treatment  to 
which  I  trace  these  changes,  are  noted  in  tables  which  I  have 
condensed  from  the  case  book  for  your  use. 

Changes  of  urine  and  iveight  of  William  S. 

During  the  first  week  the  quantity  of  urine  was     .  fl,5  680 

Of  the  specific  gravity  before  fermentation  each  day  1-042 

"                      "       after  fermentation  ....  1'012 
His  weight  had  increased  to  6  st.  12  lbs. 


DIABETES.  481 

During  the  second  week  the  quantity  of  urine  was         fl.5  449 
Of  the  specific  gravity  before  fermentation  varying 

from 1-039  to  1-040 

His  weight  had  decreased  to  6  st.  11|  lbs. 

During  the  third  week  the  quantity  of  urine  was  .          fl.5  472 

Specific  gravity 1-039  to  1-041 

His  weight  had  increased  to  6  st.  13  lbs. 

During  the  fourth  week  the  quantity  of  urine  was         fl.5  452 

Specific  gravity 1-040  to  1-042 

His  weight  had  increased  to  6  st.  13|^  lbs. 

During  the  fifth  lueek  he  lost  half  a  pound  in  weight. 


Diet  and  medicine  of  William  S. 

During  the  first  toeek  a  grain  of  opium  every  night,  mutton 
chop  for  breakfast,  ordinary  full  diet,  and  three  captain's  biscuits 
in  place  of  bread  daily. 

During  the  second  week  the  treatment  was  altered  to  eight 
grains  of  iodide  of  potassium  three  times  a  day,  with  a  drachm 
of  cod-oil;  he  was  allowed  a  captain's  biscuit  daily,  and  as  much 
meat  and  milk  as  he  could  eat  and  drink. 

During  the  third  week  the  captain's  biscuit  was  changed  to 
bran  biscuit;  but  in  point  of  fact  he  did  not  eat  that  substance, 
preferring  to  go  without  bread-stuffs  altogether. 

During  the  fourth  week  no  change  was  made. 

In  the  fifth  tveek  we  tried  Bouchardat's  gluten  bread  in  vain. 

The  first  practical  point  to  be  observed  in  the  pathology  of 
diabetes  mellitus  is  the  arrest  in  the  function  of  construction. 

That  generally  used  material  of  nutrition,  sugar,  which  ought 
to  be  assimilated  as  food,  and  made  available  to  the  growth  of 
the  body,  passes  into  the  thoroughfare  of  the  circulation,  and  out 
again  unaltered,  and  is  ejected  in  the  urine.  And  here  I  refer 
not  only  to  the  sugar  which  is  taken  as  such  into  the  mouth,  but 
also  to  that  which  is  formed  out  of  starch  by  the  action  of  the 


482  DIABETES. 

saliva.  So  that  in  one  thoroughly  diabetic  the  whole  of  the  saccha- 
rine and  amylaceous  matters  in  the  dietary  are  utterly  wasted. 
Trying  to  feed  him  upon  them  would  be  just  the  same  as  feeding 
him  upon  nothing  at  all. 

More  than  this,  I  think  you  are  doing  him  harm.  These  use- 
less articles  of  food,  though  they  contribute  nothing  to  his  sup- 
port, destroy  his  appetite,  and  so  he  does  not  eat  the  needful 
quantity  of  really  nourishing  things.  And  moreover,  the  analogy 
of  other  diseases  would  lead  to  the  conclusion  that  burdening  a 
disabled  function  with  work  to  which  it  is  unequal  will  disable  it 
more  and  more.  If  the  stomach  rejects  undigested  an  ounce  of 
beef,  it  is  made  worse  by  the  administration  of  a  steak.  If  the 
eyesight  fails,  or  the  brain  reels  on  slight  exertion,  common  ex- 
perience forbids  us  to  demand  violent  efforts. 

Therefore  you  need  not  wonder  to  find  that  cutting  oflF  a 
diabetic's  sugar,  bread,  and  potatoes,  by  no  means  lowers  him. 
On  the  contrary,  he  often  gets  heavier  under  the  restriction. 
And  one  can  easily  believe  the  instances  recorded  by  Dr.  Pavy 
where  treacle,  honey,  and  sugar,  intentionally  administered  as 
an  experiment  to  diabetics,  made  the  patients  feel  worse  and  lose 
weight. 

I  do  not  mention  in  evidence,  or  rate  of  any  importance,  the- 
increase  or  diminution  of  sugar  in  the  excretions  under  the  influ- 
ence of  saccharine  or  non-saccharine  diet.  It  is  less  when  little 
starch  and  sugar  are  taken,  it  is  more  when  much  is  taken.  But 
the  real  point  is  the  acquirement  of  flesh,  and  the  test  the  addi- 
tion of  weight.  You  will  find,  when  the  ordinary  mixed  food  of 
healthy  men  is  used  by  diabetics,  that  much  flesh  is  lost,  and  that 
it  is  regained  when  a  carniverous  dietary  is  rigidly  forced  on  them. 
With  the  flesh  also  comes  strenjirth,  showino;  that  muscle  is 
gained,  and  not  mere  fat. 

The  great  point,  then,  in  the  treatment  of  diabetes,  is  to  accus- 
tom the  patient  gradually  to  live  entirely  on  meat,  or  at  least 
entirely  on  albuminous  and  gelatinous  food.  This  need  not  seem 
a  mighty  hardship ;  the  iron-framed  Esquimaux  do  it,  and  the 
wiry,  tough,  half-breeds  of  the  Pampas,  with  a  bill  of  fare  cer- 
tainly less  varied  in  flesh-meat  than  our  European  meadows  afi'ord. 


DIABETES.  483 

You  may  then  fairly  direct  your  energies  to  attain  this  goal  with 
a  good  chance  of  success.  What  nations  live  and  increase  upon 
may  be  trusted  to  nourish  a  single  individual. 

Laying  this  down  as  the  main  point  in  the  treatment,  let  us  see 
what  is  likely  to  be  gained  by  it. 

You  will  learn  from  the  history  of  our  present  patient  that 
turning  him  into  a  carnivorous  animal  does  not  entirely  remove 
a  diabetic's  peculiar  ailment.  Twenty  days  after  all  vegetable 
matters  had  been  cut  off  from  his  diet  card,  and  he  has  been  care- 
fully w^atched  by  others  set  to  detect  any  breach  of  the  rules, 
still  the  urine  is  full  of  sugar.  So  that  it  must  be  derived  from 
some  other  quarter  than  the  starchy  and  saccharine  constituents 
of  the  food. 

We  shall  feel  less  surprise  at  this  formation  of  sugar  from  ani- 
mal matter  alone  when  we  call  to  mind  that  there  is  a  normal 
secretion  in  which  sugar  may  be  found  under  even  normal  circum- 
stances.    The  milk  of  carnivora  contains  it.* 

Moreover,  sugar  may  be  formed  in  the  TO)oratory  by  a  process 
of  decomposition  without  the  presence  of  life.  Nay,  rather  only 
w^hen  life  is  extinct.  The  simple  application  of  oxygen  will 
cause  some  animal  substances  to  be  converted  into  sugar.  This 
has  been  noticed  by  Dr.  Claude  Bernard  to  be  especially  the  case 
with  the  tissues  which  form  the  liver,  which  washed  from  blood 
and  exposed  to  the  air  quickly  become  saccharine.  So  that  your 
patient  has  a  fertile  source  of  sugar  in  his  own  body,  even  if 
none  is  supplied  by  the  aliment  consumed.  He  carries  in  his 
abdomen  about  three  pounds  of  viscus  capable  of  easy  conver- 
sion into  sugar. 

But  remark  it  is  dead  liver,  not  live  liver  which  in  health  is 
decomposed  as  above  stated.  Normal  vital  action  seems  to  have 
another  way  of  removing  the  hepatic  substance,  for  during  life 
no  sugar  can  be  detected  as  formed  from  the  organ.  Diabetes, 
then,  like  all  diseases  of  which  we  know  more  than  the  superficial 
symptoms,  turns  out  to  be  a  death  in  life,  an  antepast  of  the  post- 

*  Bensch  has  put  on  record  the  presence  of  sugar  in  the  milk  of  bitches  fed 
entirely  on  meat.  "  Annalen  der  Ch.  und  Pharm.,"  Bd.  Ixi,  221,  quoted  in  Dr. 
Lehmana's  "  Phys.  Chemistry." 


484  DIABETES. 

mortal  propertie.s  of  the  bodily  constituents.  This  is  an  addi- 
tional reason  for  casting  about  how  best  to  apply  restorative 
medicine  in  its  treatment,  and  for  urging  an  ample  supply  of  the 
right  material  for  revivifying  the  frame.  If  the  dying  liver  is 
passing  off  quickly  by  the  kidneys,  we  must  give  the  patient 
quickly  the  wherewithal  to  make  new  liver.  Now  you  gain  an 
additional  reason  for  enforcing  animal  diet  in  diabetes. 

To  accustom  this  patient  to  leave  off  by  degrees  vegetable  ali- 
ments, I  gave  him  captain's  biscuits  for  a  fortnight.  During 
that  time  scarce  any  weight  was  gained,  and  the  urine  was  but 
little  altered.  He  liked  those  biscuits  very  well.  Then  I  ordered 
him  bran  biscuits,  but  he  said  they  were  so  nasty  he  could  not 
eat  them,  and  he  wasted  some  of  his  milk  in  trying  to  make  them 
palatable.  Nevertheless  he  increased  in  weight  by  tAVo  pounds 
during  two  weeks,  and  made  eleven  pints  less  urine  weekly  than 
on  his  first  admission.  And  this  although  he  drank  as  much  as 
he  felt  disposed  to  take. 

After  this  Mr.  Van  Abbott  was  good  enough  to  give  him  a 
supply  of  the  gluten  bread  which  is  manufactured  by  his  firm 
according  to  the  prescription  of  Dr.  Bouchardat.  For  a  week 
he  tried  hard  to  eat  it  in  addition  to  his  former  allowance  of 
meat ;  but  I  am  sorry  to  say  he  failed  in  acquiring  a  taste  for 
it,  though  it  was  nicely  toasted  and  buttered.  His  appetite  fell 
off  during  the  experiment,  he  lost  half  a  pound  of  the  weight  he 
had  gained,  and  was  so  annoyed  at  being  pressed  to  eat  the  gluten 
bread  that  he  insisted  on  returning  home  on  July  12. 

My  own  opinion  is  that  we  do  not  act  wisely  in  enforcing  a 
dietary  which  is  really  unbearable  by  the  patient.  The  great 
object  to  be  gained  is  to  conciliate  the  stomach,  appetite,  and 
fancy  into  taking  the  greatest  possible  amount  of  animal  food, 
and  if  practically  you  find  that  the  patient  eats  the  heartier  for 
having  a  biscuit,  or  a  crust,  or  even  vegetables  with  his  meals, 
it  is  better  to  give  him  his  way  than  to  act  the  tyrant. 

I  will  now  make  a  few  remarks  on  the  medicines  administered. 

Opium  was  given  for  a  week.  It  did  not  in  this  particular 
instance  seem  to  exercise  any  influence  at  all.  However,  in 
some  cases  it  certainly  does  seem  to  check  the  excretion  of 


DIABETES.  485 

water.  But  is  that  any  advantage  ?  or  is  it  an  adherence  to  the 
prejudices  instilled  by  antiquated  theories  that  we  reckon  on 
help  from  such  an  interference?  I  own  it  seems  to  me  that  if 
the  blood  gets  loaded  with  sugar,  as  analysis  proves  to  be  the 
case,  it  is  better  that  the  sugar  should  be  washed  out  by  an 
ample  diuresis,  than  that  it  should  remain  at  the  risk  of  poison- 
ing the  tissues.  I  have  never  distinctly  traced  any  harm  to 
opium,  truly;  but  I  have  traced  harm  to  something  whose  action 
on  the  kidney  is  not  dissimilar.  Cinchona  like  opium  diminishes 
the  flow  of  urine,  and  I  once  gave  that  to  a  diabetic  patient. 
After  a  short  time  he  became  comatose,  and  after  death  I  found 
a  collection  of  fluid  in  the  ventricles  in  the  brain.  The  eff"used 
serum  was  loaded  with  sugar,  which  it  Avas  the  business  of  diu- 
resis to  have  diluted  and  washed  away. 

For  this  reason  I  shun  cinchona  in  diabetes,  even  when  I  wish 
to  give  tonics  for  the  sake  of  increasing  appetite.  I  prefer  iron 
and  strychnine.  An  elderly  patient  of  mine  with  moderate  dia- 
betes is  now  taking  them  with  advantage  to  his  strength  and 
digestion,  and  without  any  hurtful  action  exhibited  in  the  urine. 

The  iodide  of  'potassium  which  you  see  prescribed  on  the  medi- 
cine card  was  given  on  purely  empirical  grounds.  There  are 
no  articles  of  materia  medica  known  to  do  good  to  the  essential 
phenomena  of  diabetes;  there  were  no  secondary  symptoms  de- 
manding special  medication ;  so  I  thought  it  a  fair  case  for  an 
experiment.  The  result  was  that  at  all  events  no  harm  was 
done;  the  patient  continued  to  gain  weight  and  strength,  and 
did  not  exhibit  any  of  the  usual  symptoms  of  intoxication  by 
iodine. 

This  is  not  like  substituting  an  experiment  in  search  of  a  pos- 
sible specific  in  the  place  of  rational  treatment ;  such  conduct  is 
indeed  most  blameworthy;  but  here  there  is  no  remedy  omitted, 
for  there  is  none  that  ofiers  any  hope  of  its  possessing  an  altera- 
tive agency,  and  it  is  a  question  of  either  something  new  or  a 
mere  placebo.  I  shall  try  the  iodide  again  on  the  next  similarly 
pure  and  uncomplicated  case. 

People  sometimes  feel  a  doubt  how  far  they  ought  to  gratify 
the  patient's  unnatural  thirst.    On  this  point  the  same  considera- 


486  DIABETES. 

tions  weigh  with  me  which  influence  my  objection  to  cinchona. 
I  think  there  ought  to  be  kept  up  a  flow  of  water  through  the 
system  in  proportion  to  the  abnormal  quantity  of  sugar  in  the 
blood,  in  order  that  no  retention  or  discharge  in  unusual  places 
of  this  material  may  take  place.  I  therefore  let  patients  drink 
as  much  as  they  feel  disposed  for. 

You  will  find  that  the  demand  for  fluid  food  is  closely  propor- 
tioned to  the  quantity  of  sugar  required  to  be  got  rid  of.  Thus 
when  the  dietary  is  changed  from  starchy  to  meat  food,  much 
less  is  drunk,  and  much  less  is  evacuated  by  the  kidneys,  though 
no  restriction  is  placed  upon  the  thirst.  Such  was  the  case  with 
the  lad  now  lectured  on ;  during  the  second  week  he  made  twelve 
^pints  less  urine,  though  he  was  recommended  at  the  same  time 
to  drink  as  much  water  as  he  liked.  The  specific  gravity  also 
of  the  secretion  was  not  raised,  which  it  certainly  would  have 
been  had  the  diminution  in  quantity  depended  on  any  other 
cause  than  a  diminution  of  the  instinctive  call  for  diluents.  I 
believe  the  thirst  depends  on  the  saccharine  contents  of  the 
blood ;  it  is  therefore  wise  to  gratify  it,  and  to  provide  the 
normal  outlet  for  the  abnormal  constituent. 


LECTURE    XXXIX. 

MORTIFICATION. 

Complete  death  of  a  part,  contrasted  with  nekrohiosis — Case  of 
■mortified  toes  from  cold  and  senile  arteries — Treatment  ex- 
plained— Preservation  of  dead  tissue  from  decomposition — 
Defence  of  weak  vessels — Food — Appetite — Action  of  oxygen 
on  sore  jjlaees — Carbonic  acid  the  normal  atmosphere  of  in- 
ternal parts — Superiority  of  nature  s  surgery  to  mans. 

{Clinical,  St.  Marys,  June  27,  1862.) 

The  greater  part  of  my  lectures  have  been  taken  up  with 
those  forms  of  partial  interstitial  death,  those  mixtures  of  half- 
life  and  half-death  in  the  same  substance,  which  constitute 
morbid  actions.  Schulz,  with  a  happiness  which  excuses  the 
pedantry,  calls  them  "nekrobiotic  processes."  I  wish  now  to 
call  your  attention  to  complete  death,  or  "nekrosis,"  I  do  not 
mean  complete  death  of  the  whole  body; — I  said  the  few  words 
I  had  to  say  on  that  head  in  my  introduction — but  complete 
death  of  a  part,  the  general  life  remaining  untouched. 

You  had  an  excellent  example  on  which  to  study  this  phe- 
nomenon in  an  old  man  who  has  been  in  the  wards  for  the  first 
five  months  of  this  year  with  mortification  of  the  foot. 

His  history  is  as  follows: — 

G.  B.,  aged  sixty-six,  is  a  cowman  of  steady  religious  habits 
(as  I  learn  from  a  cousin  of  his  whom  I  know  speaks  truth,  for 
she  taught  me  to  do  so — in  fact  my  nurse),  living  very  tem- 
perately on  small  wages,  seldom  eating  meat,  and  still  more  sel- 
dom taking  beer  or  any  alcoholic  drink.  In  appearance  he  is 
quite  a  model  for  Burns'  cottar.  His  health  has  been  as  good 
as  he  deserves,  though  he  has  felt  for  the  last  twelve  months  or 


488  MORTIFICATION. 

thereabouts  not  quite  so  young  as  he  was,  and  you  may  observe 
a  signfit  f  age  in  the  eye,  an  arcus  senilis  around  the  iris.  In 
the  aefpond  week  of  last  December  he  got  a  severe  chill  by  sit-  I 
ting' for  several  hours  in  wet  clothes.  He  had  then  much  pain 
in  the  left  foot,  and  he  observed  that  it  was  swollen  and  that  its 
nails  were  livid.  This  blueness  and  swelling  passed  off  when  he 
had  laia  up  for  a  few  days,  and  then  he  went  to  his  work  again. 
But  a'fiChristmastide  ae-ain  he  got  wet  through,  and  back  came 
the  pa^^n  in  the  foot  and  ankle.  On  looking  at  it  he  found  all 
the  tofts  above  and  below  and  their  balls  quite  black,  the  black- 
ness 1  aching  about  half  an  inch  beyond  the  balls  in  towards  the 
hollox  of  the  sole.  Sensation  here  was  quite  lost,  the  whole 
foot  ai®d  ankle  were  swollen,  red,  and  very  painful,  the  pain  ex- 
tendir  p  the  inside  of  the  leg.  In  this  state  he  came  into  the 
hospiy,  -  on  January  3.  His  appetite  then  Avas  quite  gone,  the 
tonguij  was  smooth  and  clammy  with  a  brownish  center,  the 
pulse  large  and  empty  Avith  the  sharp  stroke  usual  in  old  age. 
Nothing  abnormal  could  be  detected  by  auscultation  in  heart  or 
lungs. 

He  was  laid  in  bed  with  the  foot  raised  above  the  level  of  the 
body.  The  leg  was  Avrapped  in  cotton  avooI,  and  kept  Avarm  with 
a  hot  bottle.  The  swelling  went  doAvn,  and  circulation  returned 
to  the  ankle  in  a  week.  An  offensive  smell  being  perceived  to 
ooze  out  from  some  weeping  cracks  between  several  toes,  the 
foot  was  kept  in  charcoal  powder.  When  after  two  months  the 
gangrene  began  to  separate  at  the  edges,  a  fermenting  yeast 
poultice  was  applied  night  and  day.  For  three  weeks  he  had 
"tea  cup  diet,"  i.  e.  a  tea-cup  of  beef-tea  or  milk  every  tAvo 
hours,  and  from  four  to  six  ounces  of  port  wine  and  bark  daily. 
He  then  recovered  appetite,  and  ate  meat  largely,  going  on  with 
his  wine.  At  the  end  of  May  he  went  out,  having  lost  the  last 
phalangeal  bones  and  the  cellular  tissue  from  each  toe,  some 
from  the  sole  of  the  foot,  and  his  old  nails.  However,  new 
though  deformed  nails  are  growing. 

The  object  of  this  treatment,  as  you  may  readily  guess,  was 
not  to  restore  life  to  the  completely  mortified  parts,  but  to  the 
mortif}'ing  tissue  in  their  neighborhood.  Our  province  is  not  to 
raise  the  dead,  but  to  heal  the  sick. 


MORTIFICATION.  489 

The  only  attention  which  I  paid  to  the  destro^^  ed  portions 
was  to  prevent  them  from  putrefying,  and  to  keep  them  v  'tached 
as  long  as  possible  to  their  parent  foot.  You  will  perL'ps  say, 
"  Why,  Mezentius-like,  bind  the  living  to  the  dead  in  aaieful 
union  ?  Why  not  rid  the  poor  man  of  what  he  can  never  use 
again  ?"  There  are  several  objections  to  such  a  trenchant  course 
of  procedure.  In  the  first  place,  probably  your  rou/h  hand 
would  root  up  the  wheat  witli  the  tares,  and  could  bar'  y  help 
cutting  away  much  tissue  capable  of  regaining  vitality.  Se  ;ondly, 
the  wound  would  still  further  render  inefficient  the  degenerated 
blood-vessels  which  were  the  cause  of  the  disease;  the;  would 
be  unequal  to  the  task  of  healing  up  the  sore,  and  furth  •  mor- 
tification would  be  likely  to  ensue.  Thirdly,  there  is  n  •  better 
guard  for  the  dying  tissue  than  the  dead  tissue  whic^  xactly 
fits  on  to  the  place,  and  shuts  out  the  air  more  thoroug.  than 
any  plaster  ever  invented.  There  must,  however,  be  tl.  s  pro- 
viso, that  it  does  not  get  putrid,  so  as  to  be  a  nuisancr  to  its 
neighbors. 

With  the  view  of  securing  this  preservation  from  decay,  we 
adopted  precisely  the  principle  on  which  meat  is  preserved  for 
food — we  kept  the  tissue  from  air,  we  kept  it  from  moisture, 
and  we  salted  it.  The  foot  was  carefully  wrapped  up,  first  in 
cotton  wool,  and  then  in  charcoal  powder.  But  moisture  at 
last  began  to  soak  out  from  the  inside,  and  the  parts  got  podgy ; 
then  I  used  salt  and  muriatic  acid,  which  acid,  uniting  with  the 
soda  of  the  serous  exudation,  also  formed  brine,  and  assisted  in 
hardening  the  tissue. 

So  much  for  forming  what  I  conceived  to  be  the  best  mechani- 
cal protection  to  the  weak,  half-dying  blood-vessels  and  nerves 
in  the  neighborhood  of  the  dead.  Half-dying  as  they  were, 
we  were  asking  of  them  extra  work,  even  the  growth  of  new 
connective  tissue,  new  skin,  and  a  scar — in  fact,  all  we  could 
get  out  of  them.  Urgently  needful  therefore  was  this  pro- 
tection. 

Let  all  that  is  possible  be  done  to  save  these  blood-vessels 
and  nerves  their  ordinary  work.  With  this  view  the  foot  was 
kept  absolutely  quiet,  and  raised  above  the  level  of 'the  chest; 


Ik 


490  MORTIFICATION. 

so  that  at  all  events  it  might  be  spared  the  exertion  of  the 
usual  elastic  force  in  the  vessels  to  resist  the  gravitating  blood ; 
at  the  same  time  the  defective  animal  heat  was  reinforced  by  a 
vessel  of  warm  water  always  kept  in  close  neighborhood. 

And  let  good  store  of  the  materials  for  new  tissue  be  laid  in. 
Food  was  administered  every  two  hours  in  small  quantities  and 
in  a  liquid  form,  for  the  patient's  stomach  turned  at  the  notion 
of  eating.  Bark  was  prescribed,  and  a  daily  dose  of  wine.  The 
desire  was  begotten  by  the  gratification  of  it,  and  gradually  the 
appetite  roste ;  so  that  not  only  did  he  relish  "  ordinary  diet," 
but  before  a  month  was  over  asked  for  an  extra  allowance,  in 
spite  of  being  unused  to  meat,  and  in  spite  of  having  no  exercise 
or  any  of  the  usual  calls  for  nutrition  in  muscular  exertion. 
Remark  here  that  you  must  not  wait  till  a  sick  body  of  its  own 
accord  asks  for  nourishment  by  instinctive  hunger.  In  health 
the  stomach  is  what  Shakespeare  calls  a  "clock  to  itself,"  but 
in  sickness  the  instinct,  or  corporeal  reason,  is  overclouded,  and 
the  spiritual  reason  must  be  its  clock.  As  life  returns,  so 
returns  the  vital  desire,  and  thankfully  confesses  the  justice  of 
the  martial  law  established  by  its  conqueror. 

As  the  new  tissue  grew  it  refused  to  be  allied  with  the  now 
foreign  substance  overlying  it ;  the  former  kinship  was  dis- 
owned ;  it  was  no  longer  bone  of  its  bone  and  flesh  of  its  flesh ; 
and  so  there  was  a  separation  at  the  edges  of  the  black  mass, 
and  some  of  the  new  birth  was  laid  bare.  An  abnormal  and 
hurtful  state  of  things  is  thus  introduced  ;  it  is  most  unnatural 
and  painful  for  tissue  to  have  to  grow  while  open  to  the  sharp 
influences  of  oxygen — the  "bitting  bitter  air,"  as  poets  call  it. 
Where  oxygen  is  intended  to  touch  a  living  surface,  that  surface 
is  closely  clothed  in  skin  or  mucous  membrane.  A  fluid  loaded 
with  carbonic  acid  is  the  healthy  atmosphere  of  an  inside  part, 
and  thick  darkness  its  light.  So  we  restored  as  far  as  we  could 
the  conditions  of  growth  and  healing ;  we  covered  up  the  part 
with  a  fermenting  poultice  of  yeast,  which  was  continuously 
giving  out  warmth,  moisture  and  carbonic  acid.  Under  its 
influence  the  restoration  went  on  prosperously. 

I  believe  an  atmosphere  like  this  of  carbonic  acid  would  be 


MORTIFICATION.  491 

exceedingly  useful  in  all  cases  of  wounds,  and  that  it  is  from  its 
production  that  internal  lesions,  as  a  rule,  heal  so  much  quicker 
than  external.  The  instinctive  surgery  of  the  dog  leads  him 
to  cover  his  wounds  with  saliva  and  warm  breath,  and  I  do  not 
think  man  can  do  wrong  in  learning  of  his  dog's  instructress, 
experience.  In  the  brute  the  experience  is  hereditary,  in  the 
man  it  is  almost  entirely  individual.  In  the  brute  it  is  purely 
selfish,  in  the  man  it  is  philanthropic. 

In  the  fourth  month  the  soft  parts,  the  connective  tissue  and 
muscles,  gradually  rotted  off,  like  the  flesh  of  the  corpses 
watched  by  the  concubine  of  Saul  and  by  M.  Devergie.*  And 
then  you  were  able  to  appreciate  the  full  advantage  gained  by 
the  conservative  practice.  Had  a  knife  been  used,  nobody 
would  have  removed  less  than  the  terminal  phalanges  of  the 
toes  at  the  very  least ;  for  they  all  looked  black  and  dead.  But 
what  do  you  see  here  ?  The  pads  of  the  toes  have  rotted  off, 
the  bones  have  dried  up  into  brittle,  brown  sticks,  which  are 
being  gradually  separated.  But  on  three  of  them  the  nails  are 
growing  ! — distorted  indeed,  and  not  ornamental,  but  still  true 
nails.  A  rough  and  ready  operator  would  never  have  thought 
of  leaving  the  little  bits  of  nail-matrix,  which  have  themselves 
grown,  and  also  given  birth  to  those  defences  so  essential  to 
comfort. 

I  have  occupied  the  greater  part  of  a  medical  lecture  with  a 
semi-surgical  case  perhaps  to  the  surprise  of  some,  who  will  cry 
"  ne  sutor  ultra  crepidam."  I  am  desirous,  however,  of  thus 
pointing  out  to  you  that  I  place  no  limit  to  the  application  of 
restorative  principles.  In  surgery  as  much  as  in  medicine  the 
thing  mainly  to  be  considered  and  treated  is  the  living  part,  not 
the  dead  part — the  normal  functions,  not  the  abnormal — the 
health,  not  the  disease.  Mark  what  is  wanting,  and  what  is  left 
whole  ;  supply  the  former,  and  use  the  latter.  Make  your  chief 
end  of  ends,  "the  renewal  of  life."t 

It  will  require  some  courage  in  you  consistently  to  follow  this 

*  See  illustration  at  beginning  of  Lecture  I. 

f  This  was  the  half-title  of  the  first  and  second  editions  of  my  clinical  lectures. 
My  reason  for  altering  it  is  given  in  the  preface. 


492  MORTIFICATION. 

advice.  You  may  be  accused  of  dishonesty  for  not  doing  more ; 
and  I  have  even  heard  it  denounced  as  quackery  to  call  that 
end  which  is  consequent  on  our  fostering  care  of  the  powers  of 
life  "  a  cure."  Were  this  true  modesty,  the  "  Non  haec  humanis 
opibus  "  of  an  laspis  or  the  "  0  altitudo  "  of  a  David,  one  would 
shrink  from  blaming  it :  but  it  is  not  so ;  a  sort  of  contrast  is 
attempted  by  assigning  the  word  "recovery"  to  such  a  result, 
and  "cure"  to  that  which  may  follow  antipathic  treatment; 
and  it  is  implied  that  no  credit  is  due  to  the  medical  attendant 
for  the  former,  whereas  by  the  latter  he  has  fairly  earned  his 
reward.  In  point  of  fact  there  is  no  contrast  at  all ;  every 
restoration  to  health  must  depend  on  a  renewal  of  the  deficient 
life ;  in  every  case  this  renewal  must  be  wrought  out  through 
the  agency  of  the  vitality  remaining  yet  uninjured  ;*  and  all 
counsel  given  by  us  which  contributes  to  bring  about  this  result 
is  strictly  curative.  Fear  not  the  charge  of  having  done  too 
litde ;  refer  to  success  as  an  evidence  of  real  activity. 

*  See  Lecture  II. 


LECTURE    XL. 

IMPORTANCE   OF  THE    DICxESTIVE   ORGANS   IN 
THERAPEUTICS. 

Disease  of  the  digestive  viscera  affects  the  whole  body — Instances, 
tuberculosis,  degeneration,  mental  disease,  gout  and  rheuma- 
tism— Digestive  viscera  the  chief  recipients  of  remedies,  and 
not  only  of  constructive,  but  of  destructive  and  arrestive  reme- 
dies— Effects  in  disease  of  healthy  and  unhecdthy  digestion — 
Importance  of  replacing  destructive  by  the  aid  of  constructive 
action — Digestive  tract  single. 

{St.  3Iarys,  April,  1862.) 

1  AM  anxious  that  you  should  be  duly  impressed  with  the 
importance  of  the  digestive  viscera  to  the  cure  of  disease.  In 
every  case,  surgical  or  medical,  the  modification  of  the  result 
produced  by  our  efforts  depends  almost  entirely  on  how  far, 
how  wisely,  or  how  foolishly,  these  organs  are  watched  over ; 
whether  they  are  well  or  ill  treated,  either  by  the  scientific 
guidance  of  the  skilled  physiologist,  or  by  the  empirical  rules  of 
the  routine  practitioner,  or  according  to  the  tradition  of  the 
nurse,  or  the  instinct  of  the  patient.  Each  and  all  of  these  may 
be  useful  guides ;  but  where  there  is  a  difference  of  opinion,  I 
prefer  trusting  to  the  first-named  principle  of  action,  and  so  does 
the  public,  except  when  in  a  fit  of  obstinacy  or  prejudice,  and 
so,  I  hope,  will  you. 

It  will  be  my  endeavor,  then,  to  give  to  the  attention  which 
I  trust  will  be  bestowed  upon  the  functions  of  these  organs,  the 
roclv-laid  foundation  of  prescient  science,  and  not  the  sandy  sup- 
port of  mere  empiricism. 

To  an  unhealthy  state  of  the  digestive  viscera  physiology 
32 


494  IMPORTANCE  OF  DIGESTIVE  ORGANS. 

enables  us  to  trace,  by  steps  more  or  less  distinct,  several  morbid 
conditions  not  manifested  in  the  organs  themselves,  but  aiFect- 
ing  the  whole  body.  Take  for  example  the  very  common  con- 
dition, tuberculosis.  One  cannot  fail  to  connect  both  empirically 
and  rationally  this  state  of  deficient  supply.  Among  whom  is 
it  most  frequent  ?  Among  those  who  have  either  not  enough  to 
eat,  or  those  who  from  imperfect  assimilation  are  uuable  to  con- 
vert into  blood  what  they  swallow.  The  starved  fluid  does  not 
sufficiently  stimulate  the  vitality  of  the  body,  connective  tissue 
is  removed  by  metamorphosis,  and  its  place  is  supplied,  not  by 
new  healthy  connective  tissue,  but  by  a  cheesy  semi-vitalized 
substance,  which  we  call  "tubercle." 

The  next  most  frequent  material  cause  of  disease  in  the 
anatomical  structure  of  the  body  is  degeneration.  In  its  origin 
it  is  closely  related  to  tuberculosis.  Unrenewed  effete  particles 
remain  as  fat  in  the  tissues ;  and  so  you  get  softened  and  dilated 
hearts,  fatty  liver,  Bright's  kidney,  atrophic  softening  of  the 
brain,  apoplexy,  &c. 

To  the  same  cause  may  be  traced  an  obscure  inefficiency  of 
mind,  very  common  among  our  chronic  invalids  and  those  whose 
circulation  and  vital  metamorphosis  is  languid.  They  complain 
that  they  awake  in  the  morning,  not  only  unrefreshed  by  sleep, 
but  seemingly  more  tired  than  when  they  went  to  bed.  There 
is  an  unaccountable  despondency  and  carelessness  about  the 
future,  accompanied  by  a  conviction  that  something  or  another 
unfortunate  is  going  to  happen.  They  have  no  power  to  pre- 
vent this ;  and  they  are  not  sure  they  would  exert  the  power  if 
they  had  it.  Their  unwilling  limbs  are  dragged  languidly  to 
the  daily  task,  but  they  are  quite  unable  to  do  anything  as  they 
ought.  The  figures  get  confused  as  the  merchant  adds  up  his 
ledger  ;  the  clerk  knows  he  has  some  important  duty  to  perform, 
but  cannot  call  to  mind  what  it  is ;  to  the  matron  even  the  light 
labors  of  daily  housekeeping  are  a  heavy  burden.  A  morbid 
dislike  to  the  idea  of  food  causes  the  family  meal  to  be  simply 
repulsive.  Sleep  is  sought,  and  perhaps  obtained,  but  is  broken 
by  painful  dreams,  or  fidgets,  or  wakefulness.  If  there  is  an 
inborn  or  hereditary  tendency  to  insanity,  now  is  the  time  when 


IMPORTANCE  OF  DIGESTIVE  ORGANS.  495 

it  bears  fruit ;  spectral  illusions,  derisive,  tempting,  or  foolish 
voices  half  deceive,  half  irritate  the  victim  ;  and  he  is  fortunate 
if  he  is  saved  from  crime  or  a  mad-house  by  the  curable  source 
of  his  unhappy  state  being  correctly  traced.  But  if  there  is  no 
previous  tendency,  the  mental  miseries  may  go  on  for  years,  and 
yet  not  produce  any  positive  unsoundness  of  mind.  In  these 
cases,  without  further  symptoms  even  than  those  named,  you 
may  be  safe  in  referring  the  origo  mali  to  the  digestive  canal ; 
and  the  success  of  your  treatment  will  usually  confirm  your  diag- 
nosis. The  special  pathological  state  I  conceive  to  be  a  torpid 
circulation  of  blood  in  the  abdomen,  by  which  the  due  nutrition 
of  the  body  is  arrested. 

There  is  also  a  suspicion  that  some  acute  diseases  of  the 
fibrous  tissues,  such  as  gout  and  rheumatism,  may  be  due  to 
imperfections  of  the  digestive  organs.  During  these  ailments 
organic  acids,  uric  or  lactic,  and  perhaps  others  yet  unnamed, 
are  found  in  excess  over  the  alkalies ;  or  rather  more  correctly 
speaking,  the  alkalies  are  in  a  state  of  deficiency  in  respect 
of  the  quantity  of  acid ;  and,  as  acids  are  certainly  formed  by 
the  decomposition  of  the  food,  and  one  of  them  (the  lactic)  espe- 
cially in  great  abundance,  Avhile  the  alkalies  also  come  from  the 
food,  it  is  presumed  that  the  cause  of  the  malady  resides  in  the 
viscera  which  contains  the  food  during  digestion.  This  idea 
that  the  digestive  organs  are  to  blame  for  gout  and  rheumatism 
is  of  very  old  date ;  yet  it  must  be  confessed  that  the  evidence 
for  it  does  not  increase ;  and  it  remains,  as  of  yore,  a  strong 
presumption,  waiting  to  be  confirmed  by  a  physiological  tracing 
of  its  steps. 

Whatever  value  we  may  attach  to  the  evidence  of  the  depend- 
ence of  diseases  on  the  digestive  organs,  it  is  very  clear  that  we 
look  to  them  for  relief  from  those  diseases.  Out  of  the  six  or 
seven  hundred  forms  of  medicines  in  habitual  use,  very  few  in- 
deed are  not  occasionally  offered  to  the  stomach  for  acceptance, 
and  an  overwhelming  majority  of  them  are  adapted  for  use  only 
in  this  way.  If  we  are  still  to  employ  this  time-honored  agency 
in  our  attempts  to  cure  bodily  ailments  (and  I  see  no  threatening 
of  a  change  at  present),  it  is  surely  a  matter  of  great  interest  to 


406  IMPORTANCE  OF  DIGESTIVE  ORGANS. 

secure  the  active  Avorking  condition  of  the  stomach.     It  is  waste  _ 
toil  to  try  and  enter  locked  doors. 

A  great  advantage  of  paying  special  attention  to  the  digestive 
organs  is  that,  as  a  rule,  they  are  more  directly  curable,  and 
that  by  their  means  distant  parts,  otherwise  out  of  our  control, 
may  be  favorably  influenced.  The  evil  of  neglecting  them  is 
obstinate  disobedience  of  the  disease,  or  rather  of  the  body  of 
the  patient,  to  any  medicine  administered. 

Let  it  be  observed,  that  it  is  not  constructive  agents  only,  not 
alone  aids  to  the  normal  work  of  the  alimentary  canal,  that  we 
try  to  put  in  through  its  walls.  We  look  to  it  also  to  take  up 
those  whose  agency  is,  physiologically  speaking,  the  direct  con- 
verse, whose  eifect  is  that  of  augmenting  destructive  metamor- 
phosis. We  call  upon  the  bowels  to  absorb  calomel  as  well  as 
bark  and  wine  and  oil.  We  sball  find  it  then  of  equal  import- 
ance to  have  them  in  a  normal  state  when  our  aim  is  destruction, 
as  when  it  is  construction  or  arrest. 

When  a  sudden  poison  or  paralysis  has  fallen  on  these  gates 
of  entrance,  our  hands  are  paralyzed  too ;  the  staffs  we  lean  on 
fail  us.  What  buckets  of  physic  used  to  be  poured  through  the 
half-dead  bowels  in  our  first  epidemics  of  cholera  !  It  might 
just  as  well  have  been  thrown  at  once  into  the  night-pan  its 
ultimate  destination  if  the  patients  live  long  enough.*  So 
that  calomel  pills,  and  calomel  powders,  and  opium,  and  cay- 
enne pepper,  were  a  frequent  constituent  of  cholera  stools ;  in 
short,  I  believe  that  nine-tenths  of  what  was  swallowed  in  the 
stage  of  collapse  followed  the  same  fate,  or  the  patients  could 
not  have  survived  the  poisonous  doses  which  are  recorded  to  have 
been  given. 

But  it  is  when  reconstruction  is  the  immediate  object  of  the 
remedies  sought  to  be  administered,  that  the  importance  of  the 
digestive  organs  is  most  obvious.  Mark  the  difference  between 
two  consumptive  patients  taking  cod-liver  oil.  One,  whose  di- 
gestion has  been  carefully  brought  into  a  healthy  state,  swal- 
lows it   in    large   quantities,   at  any  time   of  day  you   please, 

*  I  once  found  a  drachm  of  ipecacuanha,  which  had  been  administered  with 
other  emetics  three  hours  before  death,  safe  in  the  cardia  of  a  patient,  in  whom 
it  had  produced  no  romiting,  and  had  not  been  moved  towards  the  pylorus. 


IMPORTANCE  OF  DIGESTIVE  ORGANS.  497 

complains  of  no  inconvenience,  enjoys  life,  does  credit  to  the 
doctor,  laughs  and  grows  fat.  Another,  in  consequence  very 
likely  of  some  easily  removable  cause,  nauseates  the  smallest 
dose  ;  if  in  spite  of  instinctive  repugnance  it  be  forced  down,  it 
gets  rancid ;  fetid  eructations  follow ;  and  the  patient  not  only 
gets  no  advantage  from  the  oil,  but  is  prevented  by  it  from  de- 
riving the  usual  benefit  from  the  daily  meals ;  appetite  is  lost, 
and  rapid  emaciation  shows  how  little  construction  is  carried  on 
in  the  tissues. 

Watch  a  case  of  typh-fever,  and  see  what  immediate  improve- 
ment follows  the  shedding  of  the  dead  epithelium  with  which 
the  mucous  membranes  have  been  coated — a  change  which  is 
announced  by  what  is  called  the  "cleaning  of  the  tongue,"  but 
which  foreshadows  much  more,  in  fact  the  cleaning  of  the  whole 
intestinal  tract.  See  how  immediately  on  this  the  poisoned 
nervous  system  begins  again  to  renew  its  life,  and  delirium 
ceases,  as  new  nervous  matter  fit  for  duty  is  generated.  Or 
watch  another  less  fortunate  case  of  the  same  malady,  how  as 
the  tongue  gets  dirtier  and  dirtier  and  drier  and  browner  each 
day,  the  weakness  of  the  nervous  and  muscular  system  increases, 
and  hope  is  more  and  more  clouded  over. 

In  both  instances,  the  difference  between  one  case  and  another, 
between  the  patient  who  is  a  credit  and  a  joy  to  us  and  the  patient 
who  continues  to  wring  our  heart  with  anxiety,  lies  in  the  more 
or  less  vitality  of  the  digestive  mucous  tract. 

Then  again,  however  skeptical  we  may  own  ourselves  as  to 
the  dependence  of  gout  and  rheumatism  upon  the  digestive 
viscera,,  it  is  through  those  organs  that  we  mostly  try  to  reach 
the  malady.  'Tis  through  those  organs  that  we  endeavor  to 
get  our  large  doses  of  potash  and  our  iodide  of  potassium  into 
the  blood.  There  are  practitioners  who,  in  their  treatment  of 
these  affections,  rest  more  exclusively  on  the  salts  named  than 
you  have  seen  me  do;  and  to  them  even  still  more  than  to  us 
must  the  integrity  of  the  digestion  be  a  care. 

We  must  remember  also,  that  it  is  of  no  use  to  employ  the 
best  possible  means  of  staying  the  morbid  symptoms,  unless  the 
digestive  organs  assimilate  sufficient  material  to  replace  that 
which   is   diseased,  and  to  remove  which  we  are  bestowing  our 


498  IMPORTANCE  OF  DIGESTIVE  ORGANS. 

pains.  Labor  is  wasted  in  clearing  away  abnormal  structure,  if 
new  structure  does  not  take  its  place.  To  that  end  the  only 
path  is  to  ensure  the  assimilation  of  food.  And  to  ensure  the 
assimilation  of  food,  the  stomach  must  be  in  working  order.  So 
that  in  point  of  fact  the  only  fair  trials  of  depletory  measures 
must  be  connected  with  feeding,  and  they  who  would  uphold 
their  good  fame  must  be  careful  of  their  patient's  digestion. 

The  digestive  tract  has  not  the  advantage  enjoyed  by  the 
respiratory  and  by  the  upper  part  of  the  urinary  apparatus,  and 
other  parts,  of  being  double.  An  animal  has  two  lungs,  two 
kidneys,  two  hemispheres  to  his  brain,  two  testicles  or  ovaries, 
but  only  one  stomach,  and  one  intestinal  canal.  This  is  a  fur- 
ther reason  for  great  caution  in  preserving  each  in  its  integrity: 
we  have  less  to  spare  for  disease  to  aifect.  A  deposit  of  tubercle 
(for  instance)  the  size  of  a  nut  in  the  pulmonary  tissue  may  be 
neither  here  nor  there,  may  be  never  known  by  its  effects.  But 
put  it  in  the  heart,  in  the  peritoneum,  or  in  Peyer's  gland,  and 
what  a  disturbance  is  produced  ! 

This  singleness  also  helps  to  explain  the  powerful  influence 
which  derangement  of  any  one  of  its  parts  has  not  only  over  the 
whole  tract,  but  over  the  whole  body  and  mind.  No  chain  is 
stronger  than  its  weakest  link,  and  an  interruption  of  the 
function  at  one  point  is  an  interruption  of  the  whole. 

[I  do  not  therefore  think  it  will  be  out  of  place  in  a  volume 
of  lectures  selected  and  edited  as  illustrations  of  restorative 
medicine  or  the  artificial  renewal  of  life,  to  insert  several  given 
a  few  years  ago,  which  were  specially  devoted  to  a  consideration 
of  disorders  of  the  stomach  and  bowels.  I  look  upon  these 
viscera  as  a  means  of  cure,  as  an  agency  for  me  to  employ  for 
the  renewal  of  life,  in  fact,  as  part  of  my  Materia  Medica. 
The  lectures  which  follow  may  then  be  considered  as  being  upon 
the  subject  of  therapeutical  agents  rather  than  as  on  the  subject 
of  disease,  and  are  set  together  as  having  that  natural  bond  of 
union. 

Questions  of  morbid  anatomy  and  diagnosis  are  here,  as 
throughout  the  volume,  noticed  as  shortly  as  possible,  and 
pathology  introduced  only  so  far  as  may  be  needed  to  afford  a 
reason  for  treatment.] 


LECTURE   XLI. 

INDIGESTION   IN    GENERAL. 

Jiistijicatian  of  the  term  as  designating  a  class  of  diseases — 
Position  of  it  in  nosology — Its  importance — Uxamjyles — Its 
action  on  chronic  disease — on  acute  disease — Use  and  abuse 
of  purgatives — Cause  of  death  in  acute  fevers — Mode  of  in- 
troducing food. 

[Extra  course  given  at  St.  Mary's  in  the  Summer  Session 
of  1857.) 

The  term  "indigestion"  or  "deranged  digestion"  speaks  to 
the  mind  of  the  physician  of  a  very  large  class  of  morbid  phe- 
nomena, various  in  their  nature  and  appearing  under  a  great 
variety  of  circumstances.  There  are  those  who  would  banish 
the  words  from  our  nomenclature;  some  because  the  outward 
manifestations  are  so  diverse  that  it  is  impossible  to  bind  them 
together  in  any  symptomatic  nosology;  some  because  the  parts 
of  the  body  whose  morbid  states  induce  indigestion  are  so  many 
that  it  cannot  be  brought  under  any  anatomical  arrangement.  It 
is  quite  true  that  a  definition  of  it  cannot  be  given  according  to 
the  symptoms,  and  equally  true  that  it  cannot  be  called  a  disease 
of  one  part  or  of  any  set  of  parts  or  tissues.  When  symptomatic 
phenomena  are  made  the  principle  of  classification,  those  atten- 
dant on  this  morbid  state  are  so  numerous  and  so  discordant 
that  they  appear  in  every  class ;  and  if  the  organs  that  originate 
diseases  are  employed  to  give  them  names  also,  there  are  very 
few  organs  in  the  body  which  do  not  sometimes  produce  the 
disorder  in  question.  Still  to  the  practitioner  and  to  the  common 
sense  of  the  non-medical  public  the  name  has  a  distinct  meaning, 
and  is  a  definite  guide  to  action.     No  nosological,  anatomical, 


500  INDIGESTION  IN  GENERAL. 

or  even  chemical  considerations  have  prevailed  over  it,  simply 
because  it  indicates  a  true  thing,  because  it  applies  to  a  class  of 
disease  having  a  connecting  link  in  nature,  though  not  in  some 
of  our  artificial  systems. 

The  common  link  which  ranges  into  one  class  the  diseases  of 
deranged  digestion  is  a  partial  defect  in  the  necessary  supply  of 
that  of  which  the  body  is  built  up,  before  it  arrives  at  the  medium 
of  distribution ;  these  diseases  are  anterior  to  assimilation  and 
to  the  blood;  they  intervene  between  life  and  the  new  matter 
which  it  seeks  to  renew  itself  withal. 

This  explains  the  fact  mentioned  before  and  familiar  tons  all, 
of  deranged  digestion  affecting  more  or  less  all  the  functions  of 
the  body,  and  producing  such  a  variety  of  morbid  phenomena 
as  immediate  or  remote  consequences.  It  perverts  incipient 
life  at  its  very  source,  and  therefore  perverts  all  its  future 
manifestations. 

I  am  very  anxious  that  you  should  have  brightly  pictured  on 
your  minds  this  idea  of  the  position  in  pathology  of  diseases  of 
digestion.  It  is  of  the  utmost  importance  in  your  treatment  of 
patients.  It  is  of  no  use  for  you  to  pour  in  remedies,  however 
suitable  for  the  removal  of  some  morbid  constituents  of  the  body, 
if  the  new  material  Avhich  is  to  replace  it  is  itself  insufficient  in 
quantity  or  moi'bid  in  quality.  While  if  you  set  to  work  in 
another  way,  and  endeavor  to  provide  healthy  material,  this  of 
itself  will  act  as  a  remedy,  even  though  other  treatment  should 
have  been  neglected.  Make  it  a  universal  rule,  then,  that  the 
special  medication  is  never  to  interfere  with  or  take  the  place  of 
the  supply  of  the  materials  of  life. 

In  the  manaofement  of  a  deranged  digestion,  whether  exist- 
ing  alone  or  as  a  complication  of  other  complaints,  it  is  certainly 
important  to  know  what  organs  are  in  any  of  the  degenerated 
conditions  Avhich  form  the  province  of  the  morbid  anatomist. 
Your  prognosis  is  modified,  and  to  some  extent  your  treatment 
is  affected  by  such  knowledge.  I  do  not  deny  the  importance 
of  this,  but  I  assert  that  it  is  infinitely  more  important  to  observe 
the  functional  disturbances  which  are  the  immediate  impediments 
to  the  healthy  renewal  of  the  body,  and  to  learn  how  to  modify 


INDIGESTION  IN  GENERAL.  501 

them  for  the  advantage  of  the  patient.  You  may  remember  my 
pointing  out  in  the  hospital  the  other  day,  with  respect  to  a  con- 
sumptive man,  how  little  it  helped  us  to  know  that  half  of  the 
upper  lobe  of  each  lung  was  filled  with  crude  tubercles:  pulmo- 
nary remedies  had  been  of  no  benefit  to  him ;  but  the  reflec- 
tion that  the  stomach  was  secreting  an  excess  of  mucus  at  the 
same  time  with  the  lungs,  led  to  effectual  means  for  the  relief  of 
the  poor  man's  progressive  emaciation,  cough,  and  other  dis- 
tresses. I  also,  a  few  weeks  ago,  called  your  attention  to  a  girl, 
the  mitral  orifice  of  whose  heart  was  narrowed  by  rheumatic  in- 
flammation in  childhood.  On  her  being  carried  into  the  hospital, 
her  face  was  like  that  of  a  corpse,  and  she  could  not  stand  with- 
out fainting  from  palpitation.  I  presume  no  sane  student  would 
expect  to  see  remedies  applied  for  the  dilatation  of  that  mitral 
orifice  whose  contraction  is  the  source  of  evil :  despair  was  not 
an  illogical  conclusion  from  the  diagnosis,  and  I  was  but  little 
surprised  to  hear  the  remark  "this  is  not  much  of  a  case  for 
treatment."  Yet  observation  of  the  functional  state  of  the 
alimentary  canal,  indicated  by  the  oedematous  tongue  and 
fauces,  made  me  express  an  expectation  that  she  would  walk 
home  with  color  in  her  cheeks.  This  she  has  been  able  to  do, 
and  the  better-nourished  heart  now  beats  steadily  and  evenly; 
though  its  mital  orifice  is  as  small  as  ever,  if  the  ear  and  stetho- 
scope are  to  be  trusted. 

On  stating  in  consultation  an  opinion  that  some  viscus  is 
chronically  degenerated,  one  is  often  met  by  the  remark,  "  Well, 
what  is  to  be  done  ? — we  cannot  cure  that?"  Very  likely  not; 
then  try  and  find  something  else  which  you  can  cure.  In  the 
great  majority  of  your  patients  you  may  find  this  curable  some- 
thing in  functional  impediments  to  the  entrance  of  nutriment 
into  the  medium  of  assimilation  ;  and  when  you  once  can  get 
nutriment  in,  it  will  act  as  the  best  medicine.  Do  not,  therefore, 
give  way  to  despair  even  after  it  has  become  certain  that  the 
principal  viscus  which  gives  a  name  and  origin  to  the  disease  is 
incurable.  And  repress  any  conscientious  fancies  that  you  are 
not  fairly  earning  your  fees  in  giving  careful  attention  and 
advice,  though  you  prescribe  little  for  the  organ  mainly  affected. 


502  INDIGESTION  IN  GENERAL. 

It  is  never  too  late  to  try  and  administer  to  the  failing  organ 
the  most  potent  of  all  medicines,  the  healthy  human  blood  of 
the  patient  himself. 

The  more  I  see  of  disease  the  more  convinced  I  become  that 
the  most  important  function  for  us  to  pay  attention  to  in  all 
cases  is  the  digestion ;  in  chronic  cases  it  outweighs  all  the 
other  functions  put  together.  I  am  led  to  this  conclusion  not 
so  much  by  physiological  reasonings,  or  by  the  important  posi- 
tion of  this  function  in  the  great  circle  of  life,  as  by  observation 
of  the  effects  of  remedies,  prescribed  perhaps  with  quite  different 
views,  and  often  without  any  thought  of  the  digestion  at  all. 
The  effect  of  climate,  for  instance,  in  pulmonary  consumption, 
is  proportioned  with  extreme  accuracy  to  the  degree  in  which 
the  absorption  of  food  is  improved  or  injured  by  it.  I  had  a 
striking  instance  of  this  a  few  months  ago,  in  the  comparison  of 
letters  which  I  received  at  the  same  time  about  a  couple  of  young 
ladies  whom  I  had  sent  to  spend  the  winter  in  a  warmer  climate. 
The  elder  (S.  S.)  was  last  year  much  the  more  advanced  in 
disease ;  half  of  the  right  lung  was  rendered  impervious  to  air 
and  immovable  by  turbercle,  local  inflammations,  hemorrhages, 
and  pleural  adhesions.  She  had  also  frequent  dysmenorrhoea, 
and  occasional  menorrhagia.  The  younger  (E.  W.)  had  a  small 
deposit  of  tubercle  at  the  apex  of  the  right  lung,  which  excited 
cough,  but  no  hoemoptysis  or  pleurisy.  She  was  the  stronger 
and  more  muscular  of  the  two,  and  had  least  right  to  hereditary 
disposition,  for  all  her  family  are  alive,  while  S.  S.  has  lost  her 
mother  by  phthisis.  Both  had  been  under  long  courses  of 
physic  by  my  direction,  so  I  set  them  to  begin  the  winter  at  any 
rate,  and  to  go  on  as  long  as  circumstances  admitted,  without 
any.  What  now  is  the  result  which  I  said  struck  me  so  forcibly  ? 
S.  S.,  the  most  diseased  anatomically  speaking,  who  had  cer- 
tainly the  greatest  amount  of  morbid  tissue  in  her  body,  found 
the  warm  air  assist  her  slusgish  circulation,  enable  her  to  take 

Co  * 

exercise,  improve  the  appetite,  and  add  unwonted  energy  and 
spirits.  No  food  was  passed  undigested,  and  the  evacuation 
from  the  bowels  was  normal  in  time  and  quantity.  The  conse- 
quence of  which  condition  of  the  assimilating  organs,  bowels 


INDIGESTION  IN  GENERAL.  503 

and  blood  has  been  a  most  decided  amelioration  of  the  pulmo- 
nary local  symptoms,  in  spite  of  an  intervening  attack  of 
haemoptysis.  There  is  scarce  any  pain,  cough,  or  dyspnoea;  she 
has  increased  in  strength  and  weight,  and  boasts  in  her  letter 
that  she  had  one  day  ridden  her  pony  five-and-twenty  miles. 
E.  W.  had  a  tendency  to  a  relaxed  condition  of  bowels — not 
absolute  diarrhoea,  but  the  passage  once  or  twice  a  day  of 
unformed  puUaceous  stools,  containing  a  large  quantity  of  undi- 
gested food.  It  was  easy  enough  by  medicines  to  prevent  the 
motions  being  too  frequent,  but  difficult  to  amend  the  assimilation 
of  aliment.  This  diathesis  seemed  aggravated  rather  than  im- 
proved  in  the  mild  climate ;  there  was  greater  and  greater 
inability  to  take  exercise ;  then  a  return  of  pain  and  tenderness 
in  the  upper  ribs,  and  at  Christmas  time  the  surgeon  in  attend- 
ance found  a  deposit  of  tubercle  taking  place  at  the  apex  of  the 
left  lung,  in  addition  to  what  already  existed  in  the  right. 
Emaciation  then  commenced,  and  continuously  progressed,  quite 
unchecked  by  cod-liver  oil  and  other  expedients,  which  I  thought 
it  right  should  be  tried,  though  without  much  expectation  of 
success.  In  this  patient  my  only  hope  is  in  the  restoration  of 
the  digestive  organs  to  a  healthy  state. 

The  remedy,  the  effect  of  which  I  thought  was  strikingly  ex- 
emplified in  this  pair  of  cases  accidentally  reported  together,  is 
soft  and  warm  air  in  incipient  consumption.  The  agreeable 
effects  on  the  respiration,  the  relief  of  dyspnoea,  the  power  of 
getting  out  into  the  open  air,  were  equal  in  both,  but  how  dif- 
ferent has  the  result  been  ! 

A  very  moderate  experience  of  the  cases  we  have  seen  together 
in  the  hospital  will  soon  enable  you  to  class  a  dozen  or  more  as 
resembling  in  their  type  one  or  other  of  the  two  above  quoted. 
The  atmosphere  of  our  Avell-ventilated  wards,  and  their  even 
temperature  in  comparison  with  the  depressing  coldness  and 
chilly  damps  of  the  streets  whence  our  patients  come,  represents 
on  a  small  scale  what  Torquay,  Madeira,  and  Mentone  are  to 
the  wealthy.  And  you  may  thus  as  students  see  what  private 
practice  will  still  more  strongly  impress  upon  you,  that  the  effect 
of  climate  on  digestion  is  the  most  important  part  of  its  action. 


504  INDIGESTION  IN  GENERAL. 

The  atmosplieric  change  alone  without  medicine  will  benefit  those 
who  resemble  the  class  represented  by  S.  S.,  more  or  less,  in 
proportion  to  the  extent  of  their  disease,  while  those  portrayed 
by  E.  W.  will  usually  grow  worse  in  spite  of  all  the  contents  of 
the  pharmacopoeia. 

In  all  forms  of  dropsy,  again,  the  effect  which  you  desire  to 
produce  by  remedies  is  strikingly  dependent  on  the  condition  of 
the  alimentary  canal.  Where  the  portal  system  is  congested,  I 
have  given  that  strongest  of  purgatives,  elateriura,  in  doses,  grad- 
ually augmented  up  to  three  grains,  without  any  of  the  vigorous 
hydragogue  action  naturally  folloAving ;  and  then,  by  applying 
a  few  leeches  to  the  anus,  so  as  to  disgorge  the  abdominal  veins, 
half  a  grain  has  produced  excessive  purgation  with  reduction  of 
the  dropsy. 

Another  striking  example  of  the  dependence  of  remedies  on 
their  influence  over  the  digestion  is  found  in  anaemia.  If,  as 
generally  happens,  iron  improves  the  condition  of  the  alimentary 
canal,  so  that  the  stools,  from  being  scanty,  scybalous,  and 
mucous,  consisting  mainly  of  wind  and  half-digested  food, 
become  natural  and  regular,  then  the  body  is  renewed  by  fresh 
nutriment,  and  the  strength  is  rapidly  reinstated:  but  if  it  irri- 
tates the  mucous  membrane,  so  as  to  make  the  evacuation  ir- 
regular, black,  and  slimy,  your  patient  remains  as  anasmic  as 
ever.  Hence  the  importance  of  suiting  to  the  case  the  different 
form  in  which  the  metal  is  presented.  If  ready  solubility  and 
presentation  to  the  absorbing  surface,  in  such  a  shape  as  to  get 
an  entrance  of  a  large  quantity  quickly  into  the  system,  were 
the  only  thing  to  be  considered,  the  question  as  to  which  is  the 
best  preparation  might  be  left  to  the  chemist.  But  it  is  not  so  ; 
very  often  the  easily  soluble  salts  so  disturb  the  gastric  mucous 
membrane  that  it  refuses  to  pour  out  that  secretion  which  is  the 
chief  solvent  of  albumen  ;  the  food  passes  unaltered  into  the  in- 
testines, and  putrefying  there,  increases  the  disease.  Whereas 
a  sparingly  soluble  form  of  the  medicament  passes  unaltered 
through  the  stomach,  and  exerts  its  main  energy  on  the  intes- 
tines. Again,  some  preparations,  both  soluble  and  insoluble, 
are  more  or  less  astringent,  and  have  various  qualities  acting  on 


INDIGESTION  IN  GENERAL.  505 

various  parts  of  the  alimentary  canal,  which  render  them  ap- 
propriate or  not  to  individual  cases.  So  that  not  the  most 
elegant,  not  the  most  praised  as  ingenious  by  the  druggist, 
is  the  oftenest  selected  by  the  judiciouS  physician,  to  whom  the 
cure  of  the  patient,  not  the  harmony  of  the  prescription,  is  the 
object  in  view. 

It  ought  to  be  better  understood  that  the  fitness  of  any  sub- 
stance ingested,  whether  food  or  physic,  for  its  final  destination, 
is  not  the  only  thing  to  be  considered.  Its  capacity  for  enter- 
ing into  the  circulation  must  be  taken  into  account,  and,  above 
all,  its  dynamic  influence  over  the  organs  of  absorption  and  di-!- 
gestion.  As  a  general  rule,  iron  is  the  chief  agent  we  think 
of  in  anaemia.  We  think  of  it  for  its  direct  power  of  increasing 
the  hrematin  of  the  blood.  Yet  it  is  by  no  means  always 
the  first,  or  even  the  best  remedy  Avhen  the  blood-disks  are 
deficient  from  faulty  assimilation.  I  remember  when  I  was  a 
student  noting  down  as  a  paradox  that  salts  and  senna  acted 
as  a  tonic  in  three  cases  running,  where  iron  and  bark  and 
bitters  had  done  no  good ;  yet  that  I  could  not  find  in  any  work 
a  tonic  action  assigned  to  purgatives.  I  then  saw  that  the  ac- 
tion of  medicines  was  not  entirely  according  to  their  rating  on 
our  books. 

The  fact  is,  that  until  you  have  removed  the  sluggish  state  of 
the  regions  presided  over  by  the  portal  circulation,  which  are 
doing  nothing  but  forming  mucus  and  obstructing  absorption, 
you  cannot  get  the  protein  compounds  taken  up,  and  they  form 
a  much  more  important  constituent  of  blood-globules  than  even 
iron. 

And  it  is  not  only  the  general  health  that  is  benefited  by  at- 
tending to  the  functions  of  the  stomach,  but  even  organs  as  far 
as  possible  removed  from  it  in  a  physiological  point  of  view. 
A  patient  consults  me  from  time  to  time  who  has  an  enlarged 
prostate.  When  digesting  well,  his  urine  is  quite  transparent, 
and  free  from  mucus,  even  when  microscopically  examined  ;  but 
if  the  stomach  is  disturbed  by  any  imprudence  or  accidental  ill- 
ness, there  is  a  copious  formation  of  pus  in  the  bladder. 

I  shall  return  to  this  subject  when  I  come  to  speak  of  medi- 


506  INDIGESTION  IN  GENERAL. 

cines  separately ;  now  I  mention  it  merely  as  an  accessible  in- 
stance to  show  you  how  all-important  in  treating  chronic  disease 
is  the  condition  of  the  alimentary  canal. 

In  acute  disease  you  "\^11  be  almost  equally  disappointed  with 
the  effect  of  your  remedies,  if  you  do  not,  either  by  iheir  means, 
or  by  other  means  in  addition  to  their  administration,  bring  the 
alimentary  canal  into  a  proper  state  for  their  reception.  In  no 
cases  is  this  more  marked  than  in  erysipelas  and  delirium  tre- 
mens, and  you  may  have  observed  that  I  scarcely  ever  pass  a  bed 
in  the  wards  containing  a  patient  affected  with  one  of  these 
diseases  without  calling  your  attention  to  the  fact.  I  point  out 
to  you  that  cinchona  and  wine  are  the  proper  remedies  for  the 
weak  rapid  pulse,  the  yellow  pasty  tongue,  and  the  low  inflam- 
mation of  the  skin  in  erysipelas ;  but  that  if  you  give  these  re- 
medies without  clearing  away  the  saburral  epithelium  from  the 
stomach  and  bowels,  they  are  quite  thrown  away;  the  circula-. 
tion  continues  as  weak  as  ever,  and  the  patient  goes  on  advanc- 
ing towards  death.  But  if  you  have  got  a  purgative  to  act,  and 
are  then  in  time  with  your  alcohol  and  bark,  the  corner  is  turned, 
and  every  change  which  takes  place  is  a  change  towards  health. 
I  have  often  shown  you,  in  the  little  room  where  we  put  raving 
cases  of  delirium  tremens,  a  man  who  has  been  taking  large 
amounts  of  laudanum,  morphia,  and  solid  opium,  yet  is  as  rabid 
and  demon-haunted  as  ever,  his  eyes  never  closing  to  the  horri- 
ble visions  that  surround  him.  But  on  giving  him  an  efficient 
dose  of  salts  and  senna  by  mouth  or  rectum,  powerful  opiates 
become  no  longer  requisite  ;  he  goes  off  into  a  quiet  sleep,  some- 
times without  any  more,  sometimes  with  an  ordinary  quantity  of 
laudanum,  and  the  next  day  he  is  usually  calm  enough  to  be  re- 
moved to  the  common  wards. 

Do  not  misunderstand,  or  suppose  me  to  have  turned  "  evacu- 
ator,"  recommending  an  artificial  diarrhoea  as  a  panacea;  on  the 
contrary,  I  am  anxious  to  warn  you  that  there  are  cases  where 
a  purged  state  of  the  alimentary  canal,  natural  or  artificial,  is 
most  injurious.  I  would  instance  especially  pneumonia  and  low 
fever.  In  the  first,  the  treatment  pursued  is  beneficial  just  in 
proportion  aa  the  bowels  are  not  purged  ;  and  if  you  give  a  ca- 


INDIGESTION  IN  GENERAL.  507 

thartic,  you  very  often  destroy  all  the  good  effect  of  your  reme- 
dies. In  adynamic  fevers,  the  prognosis  may  be  almost  entirely 
governed  by  the  average  proportion  of  solid  matter  to  the  liquid 
in  the  stools,  and  by  the  degree  in  which  the  food  is  digested. 
Any  expedients  which  increase  the  amount  of  solid  and  diminish 
the  liquid  intestinal  evacuations,  any  Avhich  promote  the  taking 
up  of  nutriment  by  the  mucous  membrane,  are  doing  good ;  any 
that  act  in  a  contrary  way,  do  harm. 

In  pneumonia  and  low  fevers,  three  quarters  of  those  who  die, 
die  of  starvation.  I  mean  that  the  real  immediate  cause  of  their 
death  is  the  non-renewal  of  the  blood  by  the  supply  of  fresh 
matter.  Both  veins  and  arteries  are  filled  with  a  dark  half-dead 
fluid,  a  great  portion  of  which  is  incapable  of  fulfilling  the  func- 
tions of  life  at  all.  Expose  this  black  blood  to  the  air,  and  it 
remains  nearly  as  black  as  ever.  No  oxygen  will  redden  it,  for 
it  is  too  dead  to  imbibe  oxygen,  and  it  is  only  fit  to  be  evacuated. 
But  then,  when  it  is  evacuated,  something  must  supply  its  place  ; 
new  blood-disks  capable  of  living  and  absorbing  oxygen  must  be 
made,  or  the  patient  dies.  If  you  think  only  of  getting  rid  of 
this  dead  matter  by  bloodletting  and  other  evacuants,  or  if  you 
think  only  of  arresting  the  rapid  destruction  of  the  still  living 
matter  by  alcohol,  you  are  taking  an  imperfect  view  of  your 
business,  and  not  doing  all  that  may  be  done  to  renew  the  pa- 
tient's life.  At  the  same  time  that  you  fulfill  the  other  indica- 
tions, it  is  your  duty  to  adopt  expedients  for  promoting  the  sup- 
ply of  nutriment  to  the  absorbents. 

That  is  not  to  be  accomplished  by  throwing  in  at  once  a  large 
quantity  of  food,  which  decomposes  and  stops  digestion  entirely. 
The  alimentary  canal  either  rejects  the  load  or  suffers  from  such 
treatment,  and  is  all  the  more  starved  by  the  very  abundance, 
like  the  Roman  girl  in  Livy's  legend,  who  was  crushed  to  death 
by  the  stipulated  rewards  of  her  treachery. 

The  way  to  attain  your  object  is  to  give  very  small  quantities 
of  food  at  a  time  and  very  frequently,  so  that  a  continuous  flow 
may  be  kept  up  through  the  alimentary  canal  without  overbur- 
dening it.  The  system  of  a  patient  laid  up  with  acute  disease 
is  like  that  of  a  new-born  infant,  in  the  weak  hold  it  has  of  life, 


508  INDIGESTION  IN  GENERAL. 

and  in  the  constant  support  it  requires;  and  the  stomachs  of  the 
two  resemble  one  another  in  the  insufficiency  of  the  meal  they 
can  take  at  once  to  satisfy  their  wants  for  any  length  of  time. 
Treat  them,  therefore,  in  the  same  way;  and  as  in  proportion  to 
its  youth  you  order  an  infant  to  be  fed  frequently,  so  in  propor- 
tion to  their  illness  feed  frequently  your  sick  patients.  A  person 
prostrated  by  a  fever  or  by  inflammation  of  an  important  vital 
organ,  such  as  the  lungs  for  example,  ought  not  to  be  more  than 
two  hours  without  food  while  awake,  and  I  have  not  unfrequently 
administered  it  in  doses  of  a  few  spoonfuls  every  hour,  night  and 
day,  with  decided  advantage. 

You  may  take  a  lesson,  too,  from  the  nursing  of  infants  as 
respects  the  nature  of  the  food;  milk  is  the  most  perfect  you 
can  give.  The  only  disadvantage  is,  that  the  caseine  may  be 
suddenly  coagulated  all  at  once  in  the  stomach,  and  then,  in- 
stead of  passing  on  gradually,  it  has  to  remain  there  till  enough 
gastric  juice  is  secreted  to  dissolve  it,  and  enough  energy  exist 
in  the  peristaltic  muscles  to  move  the  mass  onwards ;  till  which 
time  it  stops  the  way.  The  better  plan  is  to  mix  sufiicient 
lime-water  with  the  milk,  to  prevent  any  large  quantity  of  lactic 
acid  from  being  free;  much  of  the  milk  will  then  pass  the  pylorus 
uncoagulated,  or  at  any  rate  in  very  small  coagula,  and  be  di- 
gested by  the  intestinal  juice,  with  no  labor  to  the  stomach.* 

You  saw  a  month  ago,  in  the  Victoria  Ward,  a  striking  in- 
stance of  the  effect  of  mere  nutriment  so  administered  as  to  be 
capable  of  being  absorbed  in  acute  disease.  A  young  woman, 
the  subject  of  pulmonary  tubercle,  became  affected  w^ith  pneu- 
monia of  the  whole  of  one  lung.  Her  lips  were  livid;  the  pulse 
not  to  be  counted;  the  respirations  irregular,  and  between  forty 
and  sixty  in  the  minute;  there  were  rales  from  the  collecting  of 
mucus  even  in  the  bronchial  tubes  of  the  unaffected  lung;  the 
tongue  had  a  smooth  yellow  coat;  and  the  repugnance  to  food 
was  very  great.  She  had  up  to  this  period  had  nourishment 
given,  or  rather  offered,  only  at  the  usual  times  of  meals.     She 

*  On  the  action  of  the  intestinal  juice  see  Bidder  und  Schmidt;  "Die  Ver- 
dauungssiifte  (von  Darmsaft);"  and  "  Digestion  and  its  Derangements,"  bj  the 
author :  Book  I,  chap,  v,  sect.  4  and  5. 


INDIGESTION  IN  GENERAL.  509 

had  had  some  stimulants,  but  they  had  been  thrown  up.  I  then 
ordered  her  a  pint  and  a  half  of  beef-tea  and  two  pints  and  a 
half  of  milk,  guarded  with  a  pint  of  lime-water,  to  be  taken,  a 
small  portion  at  a  time  every  hour,  so  as  to  finish  the  whole  in 
twenty-four  hours.  The  next  day  a  sudden  revival  had  taken 
place;  the  tongue  had  cleaned;  the  respirations  were  about 
twenty-five  or  thirty;  and  so  she  continued  to  hold  on  to  life  for 
five  days,  when  a  relapse  occurred,  and  she  died.  She  died 
truly,  but  it  seemed  pretty  clear  that  death  would  have  occurred 
from  the  first  condition  in  which  the  patient  was  seen  by  you, 
except  from  the  continuous  supply  of  nutriment.  I  cite  this 
case  rather  than  any  of  those  Avhere  final  recovery  takes  place, 
because  in  them  you  might  doubt  whether  the  disease  really  is 
of  a  necessarily  fatal  nature ;  whereas  here  you  have  proof  of 
the  fact  in  its  killing  the  patient  soon  afterwards.  It  was  of  a 
fatal  nature,  yet  death  was  arrested  for  a  time,  and  the  sharp- 
ness of  the  symptoms  made  the  changes  more  striking  than  in 
patients  where  your  memory  has  to  cast  back  for  days  or  even 
weeks,  in  order  to  trace  the  effect  of  treatment. 

Another  patient,  now  convalescent,  illustrates  a  still  more 
purely  dietetic  treatment  of  acute  disease.  I  mean  a  young 
man  who  was  brought  in  three  weeks  ago  with  low  fever,  his 
tongue  dry  and  brown,  rose  spots  on  the  skin,  weak  fluttering 
pulse,  and  the  stools  smelling  like  rotten  flesh.  The  anly  medi- 
cine I  prescribed  was  a  small  quantity  of  chalk-and-mercury 
powder  at  night,  and  some  efi"ervescing  saline  draughts.*  You 
have  often  seen  under  such  treatment  the  fetor  of  the  stools  con- 
tinue, and  great  weakness  follow,  even  in  those  fever  cases  that 
ultimately  get  well.  But  I  ordered  at  the  same  time  a  diet  of 
milk  and  beef-tea,  to  be  taken  in  small  quantities  every  hour, 
and  a  few  ounces  of  port  wine.  To  assist  the  absorption  of  this 
nutriment  I  gave  him  also  a  scruple  daily,  divided  into  three 
doses,  of  a  powder  containing  pepsine ;  and  I  was  curious  to  know 
what  the  eff'ect  would  be  on  the  digestion,  for  it  was  the  first 
time  I  had  given  it  in  low  fever.    The  result  was  most  encourag- 

*  I  had  not  at  that  date  commenced  the  acid  treatment  of  rontiaued  fever  de- 
tailed in  a  lecture  at  the  beginning  of  this  volume. 
33 


510  INDIGESTION  IN  GENERAL. 

ing — for  tlie  stools  immediately  lost  their  putrid  fetor,  and  the 
food,  instead  of  being  passed  in  a  putrid  undigested  state,  seemed 
to  be  entirely  consumed  in  the  bowels.  In  spite  of  several  dis- 
couraging symptoms,  I  have  never  seen  a  case  of  bad  fever  where 
the  stools  were  less  fetid,  or  where  there  has  been  less  emaciation 
and  debility  during  convalescence. 

My  object  in  this  lecture  has  been  to  lead  you,  in  your  clinical 
studies  in  the  wards,  and  also  in  after  life,  to  rate  aright  the  im- 
portance of  the  management  of  the  digestive  organs  in  disease. 
I  mean  in  disease  generally,  and  not  in  that  which  specifically 
affects  those  organs  alone.  And  in  future  lectures  on  the  same 
subject,  I  intend  the  descriptions  I  give  of  morbid  phenomena, 
and  the  simple  classes  into  which  it  is  convenient  to  divide  the 
impediments  to  digestion,  to  apply  equally,  whether  they  are 
alone  and  give  a  name  to  the  illness,  or  whether  they  are  united 
to  anatomical  changes  which  afford  ground  for  a  more  convenient 
generic  designation. 

Do  not  be  deceived  by  the  expression,  "merely  symptomatic," 
sometimes  applied  to  the  derangements  of  digestion  in  phthisis, 
anaemia,  amenorrhoea,  dropsy,  hysteria,  &c.,  such  as  I  have  cited 
for  illustration.  All  parts  and  functions  of  the  body  are  so  knit 
together  to  form  the  great  circle  of  life,  that  their  comparative 
value  to  individual  existence  is  more  a  question  of  time  than  of 
power.  The  failure  of  any  one  shortens  the  days  more  or  less, 
and  a  "mere  symptom"  is  as  often  the  immediate  cause  of  death 
as  an  organic  change  or  a  pathological  process  is. 

I  shall,  in  the  five  following  lectures,  give  as  concise  a  sketch 
as  I  can  of  the  principal  modes  in  which  the  function  of  digestion 
is  deranged,  either  alone  or  in  connection  with  other  diseases, 
pointing  out  on  the  way  what  rational  indications  of  treatment 
they  afford.  I  shall  afterwards  comment  on  some  of  the  most 
important  means  used  to  effect  our  purpose,  and  point  out  their 
bearing  upon  rational  medicine. 


LECTURE    XLII. 

SLOW    DIGESTION   AND    ACIDITY. 

Healthy  digestion  is  easy,  quick,  and  complete —  Unhealthy  diges- 
tion is  painful,  slow,  and  defective — Phenometia  exhibited  in 
unhealthy  digestion — Heartburn — Acidity. 

[Extra  course,  St.  Mary's,  Summer  Session,  1857.) 

Healthy  digestion  is  easy,  quick,  and  complete.  There  can 
be  no  excess  of  it,  for  food  cannot  be  too  easily,  quickly,  and 
completely  converted  into  chyme  and  taken  into  the  system,  and 
there  is  no  such  thing  as  too  much  health. 

In  ill-health  digestion  is  impared  in  one  or  more  of  these 
qualities — it  becomes  painful,  sloiv,  defective. 

You  may  use  Greek  words,  and  call  the  above-named  erring 
qualities  of  the  digestion  dyspepsia,  bradypepsia,  and  apepsia ; 
only  remember,  that  making  the  old  adjectives  into  new  sub- 
stantives adds  no  whit  to  our  knowledge,  and,  unless  care  is 
taken,  runs  some  risk  of  being  a  stumbling-block  to  its  progress. 
For  when  we  have  in  this  way  given  a  proper  name  with  a 
capital  letter,  we  are  apt  to  think  we  have  defined  an  individual 
and  active  motive  power,  instead  of  what  is  really  the  deficiency 
of  a  function,  and  thus  we  fall  into  the  errors  of  our  forefathers, 
whose  dangerous  aims  at  destroying  their  abstract  foe  the 
"Disease,"  instead  of  restoring  the  existing  patient,  led  to  so 
much  bad  practice  in  the  generation  now  passing  away.  I  shall 
use  the  English  adjectives,  but  first  I  will  say  shortly  what  I 
mean  by  them  in  this  coneection. 

Painful  digestion  may  be,  and  often  is,  both  defective  and 
slow  ;  but,  on  the  other  hand,  it  not  unfrequently  also  is  com- 
plete   and   performed   with    sufficient   quickness.     All    that   is 


512  SLOW  DIGESTION  AND  ACIDITY. 

intended  by  the  word  is  to  express  that  it  is  accompanied,  at 
some  state  of  its  progress,  by  feelings  varied  from  slight  dis- 
comfort to  absolute  torture. 

By  slow  digestion,  I  mean  that  the  act  in  some  part  of  the 
alimentary  canal  is  not  completed  by  the  time  when  the  conve- 
nience of  the  individual  and  of  society  require  that  it  should  be 
completed.  The  stomach,  for  instance,  may  retain  so  much  of 
a  former  meal  that  it  is  not  in  a  fit  state  to  receive  the  new  one 
which  is  absolutely  required  for  the  sustenance  of  the  body. 
This  is  generally  indicated  by  a  want  of  the  natural  appetite 
which  arises  when  the  upper  portion  of  the  digestive  apparatus 
is  ready  to  do  its  work,  and,  in  chronic  cases,  by  imperfect 
nutrition,  anaemia,  debility,  &c.  Or,  if  we  attempt  to  force  food 
too  quickly  on  the  unwilling  stomach,  we  have  chemical  decom- 
position and  defective  digestion  as  consequences. 

By  defective  digestion,  I  mean  that  food  capable  of  nourishing 
the  body  cannot  do  so  from  lack  of  certain  changes  which 
it  should  naturally  undergo  in  the  alimentary  canal.  It  is 
passed  from  thence  either  unaltered  or  chemically  decomposed. 
There  are  seen  in  the  faeces,  either  by  the  naked  eye  or  the 
microscope,  lumps  of  muscular  fiber,  fat,  starch,  &c. ;  or  else 
the  products  of  their  decay,  consisting  of  various  obnoxious 
gases  and  acids,  are  developed  in  quantity  subversive  of  comfort. 

The  morbid  phenomena  accompanying  these  errors  of  the 
digestive  function  may  be  divided  according  as  they  occur 
during  the  first  stage,  that  is,  before  the  alimentary  mass  has 
passed  the  pylorus  ;  in  the  second  stage,  that  is,  during  its 
passage  along  the  small  intestines;  or,  in  the  tJdrd  stage,  after 
the  passage  of  the  ilio-csecal  nerve.  Now,  remark,  I  do  not  call, 
and  I  wish  you  not  to  call,  these  phenomena  diseases  of  the 
stomach,  or  o/the  intestines,  or  of  the  colon.  They  are  not  so, 
and  must  not  be  treated  as  such.  The  discomforts  felt  in  the 
first  stage,  for  example,  may  be  due  to  organs  far  away  from  the 
stomach, — to  the  uterus,  to  the  kidneys,  to  the  teeth, — yet  they 
may  be  called  by  the  same  names,  and  treated  by  the  same 
remedies  as  when  they  are  owing  to  anatomical  changes  in  that 
part.     So  those  of  the  second  and  third  stage  often  are  trace- 


SLOW  DIGESTION  AND  ACIDITY.  513 

able  not  to  anything  wrong  in  the  ilia  or  colon,  but  to  excess  of 
mucus  or  deficiency  of  pepsine  in  the  stomach.  This  is  a  con- 
sideration of  much  practical  importance,  for  it  much  influences 
the  treatment. 

In  the  first  stage  of  digestion  we  may  notice,  as  common 
phenomena,  those  generally  known  by  the  following  names: 

Heartburn;  Acidity;  Weight;  Tightness  (or  distention); 
Oppression  ;  Wearing  (or  boring)  pain  ;  Cramp  (or  spasms) ; 
Eructation  ;  Vomiting. 

I  would  commend  to  you  these  words  rather  than  any  new 
Greek  or  Latin  compounds  which  profess  to  include  them. 
Nine  times  out  of  ten  the  artificially  manufactured  terms  are 
not  nearly  so  accurate  as  those  which  have  become  defined  by 
daily  use. 

HEARTBURN 

is  a  sense  of  heat  or  cold  (they  are  much  the  same)  at  the  car- 
diac orifice  of  the  stomach,  running  at  intervals  up  the  course 
of  the  gullet. 

From  the  effects  which  alkalies  have  in  allaying  temporarily 
this  pain,  there  seems  no  doubt  that  it  arises  from  the  action  of 
the  acid  contents  of  the  stomach  on  the  cardiac  and  oesophageal 
nerves.  The  gastric  mucous  membrane  itself  does  not  suffer 
from  acids  ;  it  secretes  them,*  and  bears  them  in  contact  for 
the  remainder  of  the  day  without  inconvenience.  The  gullet, 
too,  will  bear  them  for  a  short  time  ;  swallowing  a  mouthful  of 
sour  victuals  or  drink  gives  a  healthy  man  no  immediate  incon- 
venience ;  but  a  continued  exposure  becomes  painful  in  close 

*  There  appears  no  doubt  about  the  gastric  juice  being  secreted  acid,  and 
becoming  neutral  only  from  admixture  with  saliva.  See  the  recent  experiments 
of  Drs.  Bidder,  Schmidt,  Griinewaldt,  and  Schroder,  compared  in  my  "Digiea- 
tion  and  its  Derangements,"  chap,  iv  ;  and  "  Experiments  on  Digestion,"  by  Dr. 
F.  G.  Smith,  Philadelphia,  1856.  This  last-named  very  valuable  renewal  of 
observations  on  the  patient  with  gastric  fistula,  formerly  a  servant  of  Dr.  Beau- 
mont's, seems  to  show  pretty  conclusively  that  in  the  human  subject  the  acid 
secreted  is  i  ot  hydrochloric,  but  probably  lactic.  The  origin  of  the  finding 
hydrochloric  acid  in  gastric  juice  is  that  the  lactic-acid  fomentation  decomposes 
the  chloride  of  sodium  contained  in  all  animal  secretions. 


514  SLOW  DIGESTION  AND  ACIDITY. 

proportion  to  its  length,  as  may  be  easily  tried  by  pouring  down 
such  articles  slowly  for  a  short  time,  whereby  pain  will  be  pro- 
duced even  in  the  most  healthy. 

Heartburn,  or  pain  from  the  action  of  acids  on  the  cardiac 
end  of  the  oesophageal  plexus,  may  arise  in  three  ways : 

1st.  By  over-sensitiveness  of  the  nerves ; 

2d.  By  too  long  exposure  to  the  acids  of  digestion ; 

3d.  By  too  much  acid  being  formed. 

(1st.)  By  over-sensitiveness  of  these  nerves.  This  is  some- 
times, but  not  always,  accompanied  by  over-sensitiveness  in 
other  parts  of  the  body,  and  is  the  form  of  heartburn  which 
weak,  nervous,  hysterical  persons  suffer  from.  It  comes  on 
almost  immediately  after  eating,  directly  the  contents  of  the 
stomach  have  begun  to  assume  that  degree  of  acidity  which  is 
natural  and  necessary  to  them.  If  vomiting  does  not  occur,  it 
continues  till  they  have  become  neutralized  either  by  the  saliva 
which  usually  flows  abundantly  down  the  oesophagus,  or  by 
taking  some  alkali,  or  by  the  moving  on  of  the  mass  towards 
the  pylorus. 

The  worst  of  this  neutralization,  natural  or  artificial,  is  that 
a  good  deal  of  the  albuminoid  food  remains  undigested.  It  is 
absolutely  requisite  for  its  solution  by  the  gastric  juice  that  it 
should  be  acid  while  in  the  stomach ;  and  if  this  natural  acidity 
is  prevented,  because  it  happens  to  be  painful  to  the  over-sensi- 
tive nerves,  the  peptic  solvent  cannot  act.  Thus  the  digestion, 
from  being  painful,  is  made  defective  also. 

A  peculiarity  of  heartburn  from  over-sensitiveness,  which 
peculiarity  often  is  a  great  assistance  to  the  diagnosis,  is  that 
one  kind  of  food  brings  it  on  as  much  as  another  ;  just  in  the 
same  way  as  the  grinding  pain  of  gastric  ulcer  (which  will  be 
spoken  of  in  a  future  lecture)  is  frequently  to  be  distinguished 
by  their  being  so  little  diiference  felt  in  the  effect  of  different 
articles  of  diet.  It  is  to  be  observed,  also,  that  it  is  very  often 
worse  after  the  early  than  after  the  later  meals,  even  though  the 
dietary  should  be  more  sparing  and  more  digestible.  Indeed, 
in  private  practice,  where  one  sees  lighter  diseases  than  those  in 
hospital  wards,  I  have  notes  of  several  patients  who  have  eaten 


SLOW  DIGESTION  AND  ACIDITY.  515 

dinners  and  suppers  without  distress,  but  who  invariably  suffered 
after  breakfast. 

This  form  of  heartburn  usually  occurs  in  nervous,  sensitive 
persons,  whether  their  state  of  system  is  congenital,  or  induced 
by  outward  circumstances.  Any  untoward  condition  of  the  parts 
supplied  by  the  abdominal  plexuses  of  sympathetic  nerves  often 
brings  it  on.  Tumors  of  the  uterus  or  pregnancy  are  a  very 
common  cause,  and  excessive  or  painful  menstruation  often 
induces  it  in  the  female  ;  and  in  the  male  I  have  known  it 
brought  on  by  piles  and  by  mere  constipation.  It  is  often 
accompanied  by  vomiting  in  persons  who  have  a  tendency 
thereto.  In  these  cases  you  have  an  opportunity  of  examining 
the  contents  of  the  stomach,  and  confirming  what  I  stated  about 
their  being  in  a  normal  condition,  by  no  means  over  acid  or 
otherwise  unnatural. 

Over  anxiety,  watching,  harassing  mental  emotions,  and,  in 
short,  all  external  circumstances  which  cause  over-sensitiveness, 
induce  this  state  of  digestion.  Local  pressure  on  the  epigastrium 
will  also  fix  the  disorder  in  that  part.  It  is  curious  that  while 
the  ordinary  nerves  of  feeling  appear  blunted  by  pressure  and 
the  frequent  repetition  of  excitement,  the  sympathetic  should  be 
made  more  sensitive.  Such,  however,  seems  to  be  the  case  with 
the  epigastric  plexus,  to  judge  by  the  frequency  with  which  this 
form  of  heartburn  occurs  in  shoemakers,  needlewomen,  clerks, 
and  others  whose  ordinary  occupations  involve  pressure  on  the 
pit  of  the  stomach. 

As  anaemia,  debility,  and  occupations  w^iich  occasion  them, 
induce  this  heartburn,  so  it,  too,  will  react,,  and  increase  them, 
or  even  bring  them  on.  An  impoverished  stomach,  thus  unable 
to  bear  the  labor  of  digestion,  becomes  poorer  still  from  defective 
supply.  That  happens  in  the  human  body  which  Martial  com- 
plains of  as  one  of  the  vices  of  civilization — those  most  in  want 
gather  least  wealth — "  Dantur  opes  nulli  nunc  nisi  divitibus." 
But  at  the  same  time  a  slight  change  of  habits,  or  slight  relief 
from  medicine,  will  equally  react  beneficially,  and  commence  a 
march  towards  health  with  unhoped  quickness. 

It  will  also  sometimes  be  associated  with,   and  very  much 


516  SLOW  DIGESTION  AND  ACIDITY. 

aggravate,  the  intermittent  lieiidache  of  marsh  miasma,  causing 
"brow-ague  "  to  begin  after  the  mid-day  meal,  instead  of  at  other 
times. 

The  suddenness  with  which  heartburn  will  come  on,  and  the 
rapidity  with  which  it  often  goes  away,  is  a  great  help  to  the 
diagnosis  of  the  nervous  origin  of  this  affection,  and  it  is  also  a 
great  encouragement  to  the  physician  to  promise  relief  to  the 
sufferer. 

The  sketch  I  have  given  of  the  physiology  of  this  disorder 
points  out  the  treatment  most  likely  to  be  successful  in  the  end. 
The  aim  must  be,  not  to  neutralize  the  acid,  but  to  blunt  the 
over-sensitiveness  of  the  nerves.  This  can  be  done,  first, 
directly,  but  temporarily,  by  medicines  known  experimentally 
to  have  that  effect  on  sensitive  nerves ;  secondly,  indirectly,  by 
strengthening  the  whole  system,  so  that  those  nerves  along 
with  it  may  become  hardier  to  bear  the  brunt  of  their  necessary 
duties. 

You  have  seen  me  often  in  the  wards  of  this  hospital  begin 
with  hydrocyanic  acid  and  bismuth,  and  in  a  few  days  proceed 
to  the  use  of  steel,  or  valerian,  or  quinine.  The  benefit  found 
from  the  first-named  medicines  is  decided  indeed,  but  it  is  tem- 
porary, and  few  cases  will  get  permanently  well  unless  they  are 
followed  up  by  the  tonics.  At  the  same  time  there  is  a  great 
advantage,  still  greater  in  private  than  in  hospital  practice,  in 
commencing  with  an  agent  whose  influence  is  immediate,  and 
which  will  gain  the  confidence  of  your  patient  for  any  future 
plan  you  may  adopt. 

Where  brow-ague,  or  any  other  form  of  neuralgia,  is  concomi- 
tant or  consequent,  you  will  best  treat  it  by  four  or  five  grains 
of  quinine,  taken  an  hour  and  a  half  before  the  meal  after  which 
it  comes  on — that  is  to  say,  in  most  instances,  the  mid-day  meal. 
I  have  found  this  more  effective  than  iron,  the  quinine  curing 
not  only  more  certainly,  but  more  rapidly. 

Sponging  the  body  with  cold  sea-water,  and  the  shower-bath, 
are  often  most  useful  remedies,  acting  doubtless  in  a  great  mea- 
sure through  the  general  system.  But  cold  sponging  or  douch- 
ing the  epigastrium,  wdiich  may  be  easily  managed  sitting  in  a 


SLOW  DIGESTION  AND  ACIDITY.  517 

hip-bath,  appears  to  have  a  special  local  action,  and  certainly 
does  still  more  good. 

The  tonics  which  must  follow  up  this  special  medication  may 
be  varied  according  to  the  case  and  the  patient's  convenience ; 
but,  as  a  general  rule,  I  find  none  do  better  than  iron. 

(2d.)  By  too  long  exposure  to  the  acids  of  digestion.  Many 
influences,  which  in  moderation  are  rather  pleasant  than  other- 
wise to  the  sensory  nerves,  become  exquisitely  painful  when  long 
continued.  For  example,  the  immersion  of  a  limb  in  water  a 
few  degrees  below  the  temperature  of  the  air  is  not  disagreeable, 
and  may  be  kept  on  with  intermissions  for  any  length  of  time; 
but  it  becomes  absolute  torture  if  persisted  in  without  an  interval 
of  rest.  So,  in  many  cases,  a  sluggish  stomach,  in  which  the 
progress  of  digestion  is  too  slow,  causes  the  cardiac  orifice  to  be 
so  long  steeped  with  acid  that  it  becomes  painful,  though  a 
proper  exposure  for  the  natural  length  of  time  could  be  borne 
with  ease.  Just  in  the  same  way,  a  continued  dribbling  of  fseces 
will  make  the  anus  sore — a  continual  running  from  the  nose  ex- 
coriate the  nares,  &c. 

This  form  of  heartburn  never,  like  the  first,  comes  on  imme- 
diately after  eating.  It  often  does  not  occur  till  four  or  more 
hours  are  passed  ;  in  fact,  till  the  period  at  which  the  stomach 
ought  to  be  nearly  empty,  and  preparing  for  another  meal.  But 
the  most  usual  time  is  an  hour  after  eating.  Its  long  continu- 
ance will,  however,  be  apt  to  induce  that  tenderness  of  nerves 
which  constitutes  the  first  form,  so  that  it  will  approach  nearer 
and  nearer  to  the  time  of  meals,  till  at  last  it  commences  imme- 
diately after  them.  It  diifers,  though  not  invariably,  in  one 
important  diagnostic  peculiarity :  that  it  is  more  common  after 
the  latter  than  the  earlier  meals.  It  will  also,  like  the  first  form, 
bring  on  nervous  headache,  and  occasionally  a  decided  intermit- 
tent neuralgia,  aggravated  by  the  same  causes,  and.  removable 
by  the  same  remedies  as  that  arising  from  marsh  miasma.  Even 
if  the  meal  should  be  omitted,  this  headache  will  still  come  on ; 
but  if  the  time  of  the  meal  be  changed,  the  time  of  the  headache 
will  change  with  it. 

Though  the  oesophagus  is  relaxed  so  as  to  admit  of  some  re- 


518  SLOW  DIGESTION  AND  ACIDITY. 

gurgitation,  yet  what  comes  up  is  seldom  more  than  air,  usually 
of  a  neutral  inoffensive  character,  and  not  in  the  great  quantities 
and  with  the  explosive  force  which  marks  the  formation  of  car- 
bonic acid  by  fermentation  in  the  stomach. 

The  persons  in  whom  it  occurs  are  active  men  of  business, 
literary  laborers,  clerks,  over-thoughtful  and  over-careful.  But 
when  once  acquired,  it  is  very  apt  to  persist  in  spite  of  a 
change  in  the  mode  of  life.  I  have  had  as  patients  thus  af- 
fected many  farmers  and  country  gentlemen  who  had  suffered 
since  youth,  though  living  with  little  apparent  care  or  intellec- 
tual occupation. 

As  before  mentioned,  it  may  lead  to  the  first  form  of  heart- 
burn ;  but  in  symptoms,  pathology,  and  treatment,  it  may  be 
considered  as  a  transition  from  it  to  the  next  in  order.  And  I 
shall,  therefore,  postpone  speaking  of  the  indications  it  affords 
till  I  have  brought  before  you  the  heartburn  which  arises — 

(3dly),  by  too  much  acid  being  formed.  To  this  the  name 
of  "acidity"  is  applied  with  propriety,  because  there  really  is 
an  excess  of  acid.  It  comes  on  at  a  period  more  distant  from 
the  time  of  meals  than  the  last  kind,  and  may  be  considered,  in 
some  respects,  as  a  further  stage  of  it.  The  pain,  however,  is 
much  less  intense  in  general,  sometimes  so  slight  as  to  cause 
scarce  any  inconvenience.  But  the  regurgitations  are  much 
greater  ;  sometimes  true  vomiting  occurs,  distinguished  by  spas- 
modic action  of  the  diaphragm ;  sometimes  only  a  teaspoonful  of 
intensely  sour  liquid  comes  up,  roughening  the  teeth,  and  bring- 
ing tears  into  the  eyes ;  sometimes  a  gaseous  acid  (acetic  and 
butyric)  is  belched  up  spasmodically ;  sometimes  it  oozes  up 
gradually,  and  its  presence  is  shown  by  the  saliva  and  breath 
being  sour  to  the  taste  and  smell. 

These  peculiarities  will  sufiice  to  distinguish  between  "acid- 
ity" or  he.artburn  from  real  excess  of  acid,  and  those  forms 
previously  named  where  the  excess  is  only  apparent.  A  further 
test  may  be  found  in  the  action  of  remedies :  a  small  dose  of 
alkali,  a  grain  or  two  of  soda  or  potash,  will  be  sufficient  to  ap- 
pease them ;  whereas,  in  this  case,  a  very  considerable  dose  is 
required. 


SLOW  DIGESTION  AND  ACIDITY.  519 

Acidity  is  often  misunderstood.  I  have  heard  it  spoken  of  as 
"  an  excess  of  gastric  juice,"  "  excess  of  action  in  the  stomach" 
— that  is  to  say,  too  much  of  a  vital  act,  too  much  life.  Such  a 
mode  of  speaking,  if  it  leads  to  anything,  must  lead  to  faulty 
thinking  and  bad  treatment.  Instead  of  being  an  excess  of 
gastric  juice,  it  is  itself  a  proof  of  deficiency.  You  may  prove 
by  experiments  on  artificial  digestion,  that  an  increase  in  the 
quantity  of  the  solvent  secretion  quickens  the  solution  of  albu- 
men. You  will  find,  for  instance,  that  the  amount  of  pepsine 
contained  in  twenty  grains  of  Boudault's  powder  will  dissolve  a 
piece  of  hard-boiled  white-of  egg  much  sooner  than  five  grains. 
The  same  thing  would  of  course  happen  in  the  stomach  ;  were 
there  more  gastric  juice  there  would  be  quicker  digestion.  But 
in  "acidity"  such  is  notoriously  not  the  case;  the  aliments 
lie  for  a  long  time  in  the  upper  part  of  the  digestive  canal, 
and  often  are,  after  all,  passed  undissolved  in  the  faeces.  It  is 
a  chemical  act  of  decomposition  directly  opposed  to  the  vital  act 
of  digestion. 

I  call  a  "vital"  act  any  which  forms  part  of  the  great  circle 
of  life,  such  as  is  the  conversion  in  the  stomach  of  albumen,  pre- 
viously incapable  of  solution  and  absorption,  into  peptone,  capa- 
ble of  entering  the  circulation.  Now,  when  this  vital  act  of 
conversion  is  carried  on  with  rapidity  by  a  stomach  making 
abundance  of  gastric  juice  strong  in  pepsine,  then  chemical 
decomposition  is  prevented ;  nay,  it  is  even  arrested  after  it  has 
commenced,  as  may  be  seen  by  putrid  meat  not  becoming  more 
but  less  putrid  as  it  passes  through  the  body  of  a  healthy  animal. 
But  when  the  conversion  is  slowly  or  imperfectly  performed,  then 
chemical  change  has  time  to  take  place,  and  does  so  very  soon, 
being  favored  bv  the  heat,  moisture,  and  animal  matter  in  a  state 
of  change.  If  the  food  remains  too  long  without  becoming  chyme, 
the  protein  compounds  putrefy  with  extreme  rapidity  under  such 
circumstances. 

Compare  this  white-of-egg  which  has  been  immersed  in  saliva 
at  the  temperature  of  100°  Fahr.  for  twenty  hours,  with  another 
portion  from  the  same  egg  kept  the  same  time  in  distilled  water. 


520  SLOW  DIGESTION  AND  ACIDITY. 

Your  nose  warns  you  of  the  difference  directly  ;  the  first  is  intole- 
rably fetid,  the  second  quite  sAveet. 

(Experiments  ahown.) 

Exactly  similar  is  the  fate  of  undigested  albuminoid  matter, 
whether  animal  or  vegetable,  in  contact  with  the  mucous  mem- 
branes inside  the  body.  But  how  does  that  affect  the  case  of 
acidity?  Thus — I  have  in  this  beaker  some  syrup  of  grape  sugar, 
quite  neutral  and  natural.  Here  is  some  of  the  same  which  has 
been  poured  on  a  piece  of  putrefying  albumen  a  few  hours  ago, 
and  kept  at  the  temperature  of  the  body.  You  see  that  a  piece 
of  litmus  paper  I  put  in  it  is  strongly  reddened,  showing  the 
copious  formation  of  lactic  acid.  In  another  beaker,  the  forma- 
tion of  butyric  acid  from  fresh  butter  by  the  same  means  is 
shown  to  you. 

[Experiments  shown.) 

Just  so  all  the  grape  sugar  and  fat  swallowed,  when  it  meets 
in  the  stomach  or  intestines  with  decomposing  animal  food,  re- 
maining in  a  mass  or  glued  to  the  side  by  a  too-sticky  mucus, 
ferments  quickly  throughout,  and  forms  lactic  and  butyric  acids, 
in  great  quantity. 

Remember,  the  grape  sugar  swallowed  means  something  much 
more  important  than  merely  the  grape  sugar  eaten.  See  this 
boiled  starch ;  I  heat  some  of  it  with  the  potassio-tartrate  of 
copper,  and  there  is  no  change  in  the  blue  color  of  the  salt. 
Now  I  put  some  in  my  mouth,  and  hohl  it  less  than  a  minute. 

[Experiments  shown.) 

See  !  when  it  is  again  heated  with  potassio-tartrate  of  copper, 
the  metal  is  precipitated,  and  shows  by  its  brilliant  yellow  color 
an  abundant  quantity  of  sugar.  The  saliva,  you  see,  begins  to 
convert  starch  into  sugar  immediately ;  very  soon  it  will  trans- 
form the  whole  mass.  A  mouthful  of  boiled  starch  Avhich  I  held 
in  my  mouth  for  five  minutes  the  other  day  showed  afterwards 


SLOW  DIGESTION  AND  ACIDITY.  521 

scarce  a  trace  of  starch  remaining.  As,  even  among  meat- 
eating  nations,  from  half  to  five-sixths  of  the  solid  food  consists 
of  starch,*  it  is  evident  that  one  of  the  most  bulky  contents  of 
the  stomach  must  be  the  sugar  which  has  been  made  by  the  saliva 
out  of  amylaceous  food.  Here  then  is  ample  material  for  the 
formation  of  lactic  acid  to  almost  any  amount.  Add  to  this  the 
oleaginous  substances  which  it  is  impossible  to  avoid  in  any  diet, 
and  which,  from  being  insoluble  in  water,  constitute  a  peculiarly 
acrid  and  concentrated  acid,  and  you  will  have  no  difficulty  in 
accounting  for  acidity,  without  recurring  to  a  theoretical  excess 
of  gastric  juice.  Acidity  then  is  an  evidence  of  chemical,  and 
therefore  of  decreased,  vital  action,  a  proof  of  incomplete  diges- 
tion, of  deficient  activity  in  the  stomach. 

On  this  rests  the  rationale  of  the  hints  for  treatment  which  it 
gives.  The  way  to  cure  it  temporarily  is  to  neutralize  by  alkalies 
the  excess  of  acid  which  is  formed.  And  this  may  be  freely 
done  without  fear  of  bad  consequences ;  for  you  are  not  likely 
by  any  reasonable  dose  to  make  it  so  far  alkaline  as  to  interfere 
with  digestion.  It  is  not  in  this  form,  where  acid  is  really  in 
excess,  but  in  the  first  (or  nervous)  heartburn  that  alkalies  do 
harm,  for  the  reasons  there  stated.  Where  it  arises  simply  from 
temporary  debility  induced  by  occasional  gluttony,  '*the  remorse 
of  a  guilty  stomach,"  it  may  be  left  to  cure  itself.  But  a  per- 
manent cure  can  only  be  brought  about  by  reagents  Avhich — 

(1st.)  Strengthen  the  local  power  of  the  gastric  solvent ; — 

(2d.)  Augment  its  quantity  ; — 

(3d.)  Excite  the  peristaltic  motions. 

The  local  power  of  the  pepsine  secreted,  although  in  diminished 
quantity,  may  be  much  increased  by  neutralizing  the  saliva 
swallowed  and  collected  in  the  stomach  and  oesophagus  just 
before  the  meal.  In  laboratory  experiments  on  artifical  diges- 
tion, you  will  find  that  saliva  arrests  the  solvent  action  of  pep- 
sine in  a  close  proportion  to  its  amount.  In  the  laboratory  you 
may  set  the  action  at  work  again  by  acidifying  the  mixture,  un- 
less you  have  waited  so  long  as  to  allow  it  to  decompose.     So 

*  See  the  dietaries  of  soldiers,  prisoners,  laborers,  and  others,  analyzed  by 
Dr.  Hildensbeim  in  ''  Die  Normal-Diiit,"  p.  6,  Berlin,  1856. 


522  SLOW  DIGESTION  AND  ACIDITY. 

too  in  the  stomach,  if  you  take  it  in  time,  you  may  free  the 
pepsine  from  the  alkaline  saliva,  and  enable  it  to  do  its  duty  by 
adding  acids.  The  best  to  select  are  those  to  which  the  viscera 
are  most  used,  hydrochloric  or  lactic,  A  few  drops  of  these 
taken  immediately  before  meals  will  almost  always  have  a  most 
beneficial  effect. 

The  quantity  of  the  gastric  juice  may  be  increased  by  sup- 
plying one  of  its  most  important  constituents,  water;  but  in 
large  quantity  at  the  meal  it  is  apt  to  dilute  too  much  the 
sparing  secretion,  and  hence  it  is  better  to  direct  the  principal 
draughts  to  be  taken  half  an  hour  afterwards.  An  artificial 
gastric  juice,  in  the  shape  of  one  of  the  new  preparations  of  pep- 
sine, may  also  be  given  if  the  acids  are  not  sufficient ;  but  I  pre- 
fer to  try  at  first  and  get  the  patient  to  be  his  own  pepsine 
maker.  The  colder  the  Avater  the  better ;  for  the  low  tempera- 
ture acts  as  a  tonic  shower-bath  to  the  local  nerves,  and  removes 
the  congestion  of  the  blood-vessels,  while  at  the  same  time  it 
never  quite  stops  digestion,  and  soon  acquires  heat  enough  to  let 
it  go  on  with  full  rapidity.* 

Your  patient  will  perhaps  think  that  you  are  blowing  hot  and 
cold,  or  rendering  inert  your  own  treatment,  by  ordering  acids 
at  one  time  and  alkalies  at  another ;  so  you  will  find  it  a  wise 
plan  to  give  him  a  short  physiological  lecture  on  the  subject,  ex- 
plaining the  reason  of  your  procedure.  You  may  explain  also 
that  the  acids  given  as  medicine  do  something  more  than  in  the 
laboratory;  they  stimulate  the  mucous  membrane,  and  so  actually 
increase  the  quantity  of  secretion  while  they  increase  its  power. 
You  need  not  have  the  fear,  which  I  have  heard  some  express, 
that  the  use  of  these  substitutes  for  the  natural  constituents  of 
the  gastric  juice,  or  rather  the  supply  of  that  which  ought  to 
exist  in  the  gastric  juice,  will  teach  the  stomach  to  be  lazy — as 
doing  a  servant's  work  for  him  makes  him  less  equal  to  doing  it 

*  That  cold  retards  the  action  of  the  gastric  solvent  is  shown  by  some  experi- 
ments on  artificial  digestion  I  published  in  "  The  Lancet,"  of  May  23, 1857.  But 
at  the  same  time  it  does  not  stop  it.  Even  the  freezing  temperature  does  not 
entirely  do  that,  as  is  proved  by  Drs.  Bidder  and  Schmidt.  "  Die  Verdauungs- 
saft,"  Exp.  ix,  1,  2;  x,  1 ;  xvi;  xvii. 


SLOW  DIGESTION  AND  ACIDITY.  523 

himself.  On  the  contrary,  the  new  vigor  put  into  the  system  by 
the  healthier  and  more  copious  chyme  that  is  formed,  renders 
the  organ  more  active  ;  so  that  it  is  soon  enabled  to  go  on  secre- 
ting for  itself  what  is  wanted,  and  to  do  without  the  artificial 
substitute.  Do  not,  therefore,  let  patients  fancy  that  they  might 
get  into  a  habit  of  taking  these  medicines,  so  as  to  be  obliged 
to  continue  or  to  increase  the  dose.  If  they  derive  benefit  from 
them,  they  will  be  able  soon  to  leave  them  off. 

The  action  of  the  peristalic  muscles  of  the  stomach  can  be 
excited  by  most  purgatives.  But  unfortunately,  in  the  great 
majority  of  gastric  complaints,  purgatives  are  decidedly  injuria 
ous,  so  that  the  good  done  to  the  stomach  is  overbalanced  by  the 
injury  done  elsewhere.  The  least  hurtful  are  rhubarb  and  aloes; 
but  even  they  somewhat  impede  the  digestion  in  many  persons 
who  take  them  as  a  dinner  pill.  A  better  expedient  is  strych- 
nine. Its  small  bulk  causes  it  to  be  quickly  absorbed,  and  to 
act  locally  on  the  stomach  alone  without  aflfecting  the  rest  of  the 
system ;  so  that  where  common  caution  is  observed,  I  have  never 
found  it  necessary  to  leave  it  ofi"  on  account  of  the  occurrence 
of  specific  spasmodic  effects ;  at  the  same  time  its  beneficial  in- 
fluence is  most  marked,  and  in  many  instances  it  acts  as  a  bitter 
tonic  also,  increasing  the  appetite  and  spirits. 


LECTURE    XLIII. 

PAIN    IN   THE   STOMACH. 

Loca  Iweight,  tightness,  distention,  dependent  on  excessive  secre- 
tio7i  of  mucus — Gastric  catarrh,  acute  and  chronic. 

[Extra  course,  St.  Mary's,  Summer  Session,  1857.) 

Weight,  Tightness,  Distention,  sometimes  a  feeling  ex- 
pressed as  of  being  "blown  out  with  wind,"  while  on  examina- 
tion the  epigastrium  is  found  not  more  tumid  than  that  of  a 
healthy  person  digesting,  are  modifications  of  a  sensation  pro- 
duced in  the  nerves  of  the  stomach  itself. 

(1.)  Alone. — Where  the  sensation  exists  alone,  unaccompanied 
by  soreness,  by  pain  on  pressure,  or  by  decided  pain  immediately 
after  eating,  it  is  possible  to  judge  of  the  real  meaning  of  the 
phenomenon.  But  in  complicated  cases  the  difficulties  presented 
are  very  great.  Putting  aside  for  the  nonce  these  latter,  and 
looking  only  to  simple  examples,  I  have  come  to  the  conclusion 
that  it  denotes  simply  the  presence  of  an  excessive  amount  of 
mucus  in  the  stomach. 

Like  other  mucus  membranes,  that  of  the  stomach  may  be 
affected  acutely  or  chronically.  The  first  case  may  be  called 
"gastric  catarrh;"  the  second,  "mucous  flux."  Both  are  liable 
to  be  followed  b^'^  vomiting,  which  relieves  temporarily  the  dis- 
tress, and  which  in  the  acute  form  constitutes  the  most  ordinary 
form  of  "bilious  attack,"  so  called  from  the  bile  which  the  action 
of  the  diaphragm  in  vomiting  causes  to  regurgitate  along  with 
the  contents  of  the  stomach.  When  not  rejected  by  vomiting, 
the  aliments  are  so  enveloped  in  mucus,  that  they  cannot  be 
acted  upon  by  the  gastric  juice,  and  are  passed  very  little 
changed  into  the  bowels,  where  they  are  liable  to  ferment,  and 


PAIN  IN  THE  STOMACH.  525 

by  their  acidity  cause  diarrhoea,  flatulence,  and  sometimes  a 
copious  discharge  of  mucus  from  the  bowels.  This  latter  result 
is  more  common  in  acute  than  in  chronic  cases,  where  the  motions 
are  often  infrequent  and  irregular,  and  exhibit  unformed  or 
scybalous  faeces. 

When  vomiting  occurs,  the  ejected  matters  are  mixed  with  so 
much  mucus  that  there  is  no  difiiculty  in  making  the  diagnosis ; 
but  where  it  does  not,  the  case  is  liable  to  be  mistaken  for  one 
of  disease  of  the  bowels,  on  account  of  the  flatulence  and  mucous 
diarrhoea.  Certainty  of  diagnosis  can  in  such  cases  be  obtained 
only  by  the  administration  of  an  emetic,  which  brings  the  source 
of  the  evil  into  the  light  of  day. 

In  acute  cases  this  excess  of  mucus  is  often  accompanied  by 
very  intense  headache,  but  in  chronic  it  seldom  goes  beyond  a 
feeling  of  stupidity.  Flushing  of  the  face,  and  heat  at  the  back 
of  tlie  eyes,  are  also  nervous  symptoms  dependent  upon  the 
chronic  condition,  and  seem  quite  independent  of  any  disturb- 
ance of  the  circulation. 

"Acute  catarrh  of  the  stomach,"  like  all  other  catarrhs,  is 
excited  by  external,  and  often  by  epidemic  influences.  Changes 
of  temperature,  are  its  most  frequent  cause.  But  still,  as  in 
other  catarrhs,  the  cause  must  have  a  special  reason  in  the 
individual  for  selecting  one  mucous  membrane  rather  than 
another.  And  since  the  naturally  warm  position  of  the  stomach, 
aided  by  the  usual  habits  of  dress,  guard  it  very  efficiently 
against  ordinary  variations  of  the  weather,  the  idiosyncrasy  of 
the  individual  has  a  preponderating  influence  in  its  production, 
and  often  leads  the  others  to  be  overlooked.  But  in  the  pre- 
vention of  the  complaint  more  is  to  be  done  by  attending  to 
these  special  reasons,  and  by  protecting  the  stomach  against 
such  deleterious  agents  as  the  habits  of  the  patient  expose  it  to, 
than  by  trying  to  alter  the  diathesis  of  his  body. 

On  the  other  hand,  the  mucous  flux  is  much  less  dependent 
on  external  circumstance,  and  much  more  on  organic  changes 
either  in  the  stomach  itself  or  some  other  viscus.  Tubercles  in 
the  lungs,  emphysema,  chronic  bronchitis,  and  enlarged  heart, 
oftenest  produce  it,  and  it  is  associated  with  cancerous,  tuber- 
34 


526  PAIN  IN  THE  STOMACH. 

cular,  and  inflammatory  affections  of  neighboring  parts,  but 
alone  it  is  rare.  In  this  it  resembles  bronchial  flux  or  chronic 
bronchitis.* 

(2.)  With  soreness  on  pressure,  more  especially  if  the  soreness 
exist  also  when  the  stomach  is  empty,  or  if  accompanied  by  a 
decided  pain  arising  from  the  indigestion  of  food,  it  denotes  that 
the  secretion  of  mucus  depends  upon  some  local  inflammation  or 
ulceration  of  a  chronic  character  in  the  mucus  membrane. 
Where  a  tumor  can  be  felt,  the  probability  is  that  it  is  of  a 
cancerous  nature.  Where  there  has  been  bloody  vomiting,  the 
diagnosis  of  ulcer,  cancerous  or  non-cancerous,  is  almost  certain. 
I  incline  to  think  that  the  peculiar  sensation  just  described 
depends  on  the  general  state  of  the  mucous  membrane,  and  not 
on  the  local  injury  to  one  part  or  another  of  the  stomach.  My 
reasons  for  thinking  so  is  that  it  is  capable  of  so  much  relief  by 
medicines  even  in  patients  where  the  spot  anatomically  altered 
is  found  afterwards  to  have  been  gradually  progressing.  Some 
of  you  may  remember  a  man  who  lay  in  Albert  Ward  during 
the  greater  part  of  a  year,  with  rapidly  growing  cancer  of  the 
liver  and  pylorus.  In  spite  of  a  continuous  increase  of  his 
necessarily  fatal  tumors,  the  sense  of  distention  and  weight 
after  food  diminished,  the  patient  rarely  vomited  his  meals,  and 
was  able  to  eat  largely.     His  being  able  to  take  a  large  quantity 

*  la  25  post-mortem  instances  of  excess  of  mucus  adherent  to  the  walls  of 
the  stomach — 

6  had  tubercles  or  vomicte  in  the  lungs  as  chief  cause  of  death  ; 
4  had  diseased  hearts  as  chief  cause  of  death  ; 

7  had  ffidema  pulmonum  or  emphysema  observed  after  death,  or  chronic 

cough  observed  during  life,  as  chief  causes  of  death. 
In  the  above  17  it  may  be  considered  as  self-evident  that  there  was  an  in- 
creased secretion  of  mucus  from  the  bronchi  as  well  as  from  the  stomach. 
Of  the  remainder — 

4  had  diseased  kidneys  as  chief  cause  of  death : 
1  pneumonia  (in  both  of  which  chronic  cough  was  not  unlikely) ; 
1  had  cancerous  ;  and 
1  tubercular  disease  of  the  peritoneum  ; 

1,  a  child  of  four  months,  had  acute   inflammation  of  the  bowels,  and  the 
mucus  was  an  evidence  of  gastric  fever,  not  of  chronic  tiux. 
(See  "Digestion  and  its  Derangements,"  by  the  author,   p.   353,  with   the 
references  to  Dr.  Jones'  paper.) 


PAIN  IN  THE  STOMACH.  527 

of  nutriment  much  prolonged  his  life,  and  his  illness  on  the  whole 
was  not  one  of  much  distress.  So  you  see  that  the  treatment 
of  even  necessarily  fat;il  cases  is  capable  of  adding  much  to  the 
comfort  of  our  fellow-men,  and  is  well  worth  the  thought  and 
attention  of  a  serious  mind. 

It  may  be  observed,  that  where  distention  with  soreness  is  de- 
pendent on  local  inflammation  of  the  stomach,  the  pain  is  constant, 
at  no  time  entirely  absent,  though  increased  by  the  ingestion  of 
food.  You  may  see  a  well-marked  case  followed  out  in  "Case- 
book" xxxix,  p.  424  (where  the  complete  cure  seems  to  show 
that  there  was  no  ulceration),  and  several  others  scattered  through 
the  books  and  indexed  as  "hsematemesis"  (where  the  throwing 
up  of  blood  seemed  to  indicate  that  lesion),  in  all  of  which  the 
discomfort  is  described  as  never  quite  wanting. 

The  excessive  secretion  of  mucus  in  the  stomach,  whether 
arising  from  ulceration  of  the  membrane,  from  chronic  inflam- 
mation of  it  or  neighboring  parts,  from  adhesion  of  the  peritoneum 
restricting  the  peristaltic  movements,  from  simple  degenerative 
thickening  of  the  secreting  structure,  from  cancer,  from  external 
pressure  (as  in  the  case  of  cobblers  or  tight-laced  women),  is  in- 
dicated by  the  sense  of  distention  above  named.  Bat  the  evil 
rarely  stops  here.  The  gastric  juice  that  is  poured  out  cannot 
penetrate  the  slimy  layer  that  envelopes,  as  in  a  bag,  the  mass 
of  aliment,  which  consequently  ferments  and  produces  all  the 
evils  arising  from  chemical  decomposition  in  the  stomach.  And 
if  the  solvent  secretion  could  get  to  them,  it  would  be  neutralized 
by  the  alkali  of  the  mucus,  and  so  rendered  incapable  of  dissolv- 
ing albumen.  Hence  heartburn  and  acidity  arise,  as  before  ex- 
plained ;  and  hence,  in  some  constitutions,  vomiting,  in  others  a 
passage  of  the  fermenting  mass  into  the  bowels,  and  diarrhoea. 

Mucus  itself  appears  peculiarly  incapable  of  being  digested. 
When  children  with  catarrhal  coughs  swallow  their  bronchial 
secretion,  you  may  often  find  it  unaltered  in  the  stools.  If  you 
try  to  dissolve  it  in  artificial  gastric  juice  in  the  laboratory, 
small  lumps  undergo  no  change  after  several  days.  Still  more, 
when  the  extensive  surface  of  the  stomach  secretes  a  large  ad- 
herent mass  of  a  peculiarly  stringy  and  firm  description,  it  is 


528  PAIN  IN  THE  STOxMACH. 

often  passed  in  large  quantities  through  the  bowels,  and  induces 
a  suspicion  that  some  part  of  the  latter  organs  are  the  seat  of 
the  evil.  And  in  truth  the  diagnosis  is  not  easy.  The  best 
guide  to  it  is  the  observation  of  the  contents  of  these  masses  of 
mucus — if  you  find  enveloped  in  the  glairy  slime  merely  brown 
granular  matter,  hairs,  threads,  the  cellular  tissue  and  husks  of 
plants,  bits  of  gristle  or  skin,  bile,  or  anything  developing  the 
natural  smell  of  fasces,  then  you  may  fairly  conclude  that  the 
mucus  comes  from  the  bowel;  but  if  there  are  bits  of  food  un- 
colored  by  bile — if,  instead  of  smelling  like  fteces,  they  are 
putrid,  or  exhale  an  odor  like  vomit,  it  is  certain  that  some,  and 
probably  the  greater  part,  of  the  mischief  lies  in  the  stomach. 
Thus  you  see  that  the  digestive  function,  in  the  cases  we  are 
now  considering,  is  "painful"  and  "imperfect,"  but  by  no  means 
necessarily  "slow;"  indeed,  in  many  cases,  the  little  digestion 
that  goes  on  is  performed  with  too  great  quickness. 

The  indications  for  treatment  derived  from  a  mucous  condition 
of  stomach  are  as  follows : — First,  it  must  be  remembered  that 
it  is  not  only  the  evidence  of  disease  (like  the  flow  from  the  nose 
in  nasal  catarrh,  for  example,  which  does  no  injury  after  it  has 
once  flowed  out),  but  it  is  also  the  cause  of  further  evil,  and 
therefore  it  must  be  directly  restrained  by  astringents. 

Secondly,  the  place  of  the  patient's  own  gastric  juice,  which 
cannot  get  at  the  food,  must  be  supplied  by  artificial  solution  of 
the  aliments,  and  their  decomposition  must  be  prevented. 

Thirdly,  alterative  diet  and  medicines,  and  local  counter-irri- 
tants, must  be  used  to  relieve  the  congested  or  degenerated  state 
of  the  organ  at  fault;  especially  in  cases  complicated  with  pain. 

Of  astringents,  I  have  found  none  act  more  directly  than  kino ; 
and  where  there  is  pain  at  the  cardiac  extremity  of  the  stomach, 
heartburn,  or  pyrosis,  the  conjunction  of  opium  with  it,  as  in  the 
pulvis  kino  compositus  of  the  pharmacopoeia,  increases  its  effi- 
ciency. Larger  doses  of  opium,  however,  in  quantities  sufficient 
to  produce  soporific  effects,  cause  headache.  A  good  test  of  the 
extent  to  which  it  is  desirable  to  give  astringents,  may  be  found 
in  their  action  over  the  bowels.  While  doing  good,  they  cause 
no  constipation;  and  in  some  instances  even  relieve  that  symptom 


PAIN  IN  THE  STOMACH.  '  529 

by  removing  the  general  state  of  irritability  and  discomfort,  and 
by  checking  the  discharge  of  mucus;  so  that  it  may  be  made  a 
rule  to  continue  them  only  so  long  as  they  do  not  constipate  the 
bowels. 

Nitrate  of  silver  is  a  very  powerful  astringent.  But  it  is  of  no 
use  unless  you  prevent  the  salt  from  being  decomposed  and  con- 
verted by  the  chloride  of  sodium  of  the  mouth  into  the  inert 
chloride  of  silver.  The  best  mode  of  securing  it  is  to  cover  the 
pill  thickly  with  gelatine,  so  that  it  remains  undissolved  until  it 
gets  to  the  right  seat  of  action. 

The  sulphate  of  iron  is  also  a  very  valuable  astringent,  espe- 
cially in  angemic  cases.  I  have  found  it  a  good  plan  to  com- 
mence with  the  nitrate  of  silver ;  and  when  obliged  to  leave  that 
off  for  fear  of  turning  the  complexion  black,  to  commence  the 
iron,  and  continue  that  until  complete  re-establishment  of  health. 
Ferruginous  waters,  especially  those  containing  the  sulphate 
(such  as  the  Moffat  and  Hartfell  chalybeates),  or  any  others 
where  the  metal  is  made  into  sulphate  by  the  addition  of  a  few 
drops  of  sulphuric  acid,  will,  of  course,  be  equally  beneficial — 
indeed,  often  more  so  from  the  addition  of  change  of  air  and 
scene. 

Another  form  of  iron  which  I  have  found  very  useful  in  gas- 
tric cases,  is  "iron  alum;"  but  I  cannot  detect  any  difference 
in  its  action  from  the  ordinary  copperas  above  recommended. 

Gallic  acid  is  also  useful,  if  a  variety  of  astringents  is  re- 
quired. But,  to  say  the  truth,  I  have  been  unable  to  detect  any 
advantage  which  one  medicine  of  this  sort  has  over  another,  and 
think  the  only  use  in  having  a  long  list  is  to  be  able  to  ring  the 
changes  upon  them,  to  prevent  the  patient  wearying  of  uni- 
formity. 

The  arrested  solution  of  the  aliments  may  be  partially  com- 
pensated for  by  a  diet  of  milk  guarded  from  coagulation  by 
lime-water,  so  as  to  postpone  its  digestion  to  the  intestines. 
The  avoidance  of  such  articles  as  are  apt  to  form  a  solid  mass 
will  do  much;  and  for  this  reason  pastry,  new  bread,  and  hard 
meat,  or  fish,  must  be  strictly  proscribed.  But  the  most  com- 
plete substitute  for  the  patient's  own  natural  secretion,  is  pepsine 


530  PAIN  IN  THE  STOMACH. 

artificially  prepared.  It  enables  solid  albuminous  food  to  be 
taken  without  distress,  increases  the  appetite,  and  raises  the 
strength.  In  the  milder  cases,  lactic  acid,  taken  before  food,  is 
sufficient. 

The  most  efficient  agent  in  preventing  the  decomposition  of 
albuminous  food  (evinced  by  fetid  evacuations,  acidity,  &c.)  is 
sulphurous  acid  combined  with  soda.  There  are  two  forms  of 
this  salt,  the  sulphite  and  hyposulphite.  Of  these,  the  former 
contains  most  sulphurous  acid,  and  certainly  does  the  work  re- 
quired of  it  most  readily.  But  then,  it  has  the  bad  quality  of 
completely  destroying  the  potency  of  gastric  juice  at  the  same 
time,  so  that  while  you  are  preventing  the  chemical  decomposition 
you  are  also  preventing  the  vital  digestion.  The  hyposulphite 
has  not  this  pernicious  effect,  and  may  also,  from  its  less  nause- 
ous taste,  be  given  in  larger  doses,  so  that  by  its  means  you  are 
able  to  do  the  good  without  the  harm.* 

By  "alterative  diet"  I  mean  a  restricted  supply  of  nutriment, 
so  that  the  destruction  of  effete  tissues  should  somewhat  exceed 
the  supply.  This  for  a  short  period  seems  beneficial  in  cases 
where  there  is  an  organic  change  in  the  tissue  of  the  stomach 
itself.  But  the  treatment  must  not  be  carried  too  far;  a  week 
is,  perhaps,  the  extreme  period  to  Avhich  the  starving  system 
should  be  carried;  if  it  does  not  do  the  good  expected  in  that 
time,  it  never  Avill. 

The  same  cases  are  benefited  by  counter-irritants,  such  as 
leeching,  blistering,  and  long-continued  water- dressings  to  the 
epigastrium.  The  advantages  of  the  first  are,  that  their  appli- 
cation is  soonest  over,  and  gives  relief  most  rapidly,  while  at  the 
same  time  it  does  not  prevent  the  use  soon  after  of  the  other 
local  remedies.  The  fear  that  this  little  loss  of  blood  will  lower 
the  patient  is  theoretical ;  for  the  increased  power  of  digestion 
adds  twice  as  much  blood  and  flesh  as  the  leeches  can  suck  away. 
In  "  Case-book  "  No.  li,  p.  223,  you  will  find  the  case  of  a  patient 
of  mine  who  was  leeched  on  the  epigastrium  for  some  time  every 
other  night,  yet  gained  twenty-one  pounds  in  weight  during  her 

*  See   "Experiments   on    Artificial   Digestion,"  Vjy  Dr.  Chambers,  in   "The 
Lancet"  of  the  23d  of  JIaj,  1857. 


PAIN  IN  THE  STOMACH.  531 

six  weeks'  stay  in  the  hospital,  so  great  was  the  relief  afforded 
in  her  form  of  indigestion.  The  advantage  of  the  wet  compresses 
as  a  counter-irritant  is,  that  they  do  least  harm,  though  at  the 
same  time  it  must  be  confessed  that  they  do  least  good,  and  are 
scarcely  adapted  for  severe  cases.  However,  in  the  milder, 
especially  where  the  person  is  not  so  ill  as  to  be  kept  from  ordi- 
nary business,  this  method  of  accomplishing  your  object  is  very 
convenient. 

The  use  of  mercury  is  beneficial  just  in  about  the  same  degree 
as  the  alterative  diet  above  mentioned  ;  immediately  it  has  be- 
gun to  have  any  good  effect  it  must  be  left  off,  or  it  will  begin 
to  do  harm.  It  is  excellent  as  an  inaugurator  or  introducer  of 
good,  but  it  does  not  carry  it  on  without  the  evil  results  showing 
themselves.  The  utmost  care  must  be  taken  that  it  does  not 
specifically  affect  the  system,  or  purge.  As  a  universal  rule, 
purgatives,  and  especially  mercurial  purgatives,  do  harm. 

"Oppression"  is  often  complained  of  at  the  same  time  with 
the  weight,  tightness,  or  distention  at  the  epigastrium.  But  it 
means  something  more,  and  is  by  no  means  identical.  Indeed, 
in  those  worse  cases  of  mucus  on  the  stomach,  which  relieve 
themselves  by  vomiting  or  by  rapidly  passing  on  with  the  ali- 
mentary mass,  there  is  no  oppression  at  all.  On  the  other 
hand,  there  are  frequent  instances  of  much  discomfort  where 
the  patients  do  not  at  all  assent  to  the  description  of  a  weight  at 
the  pit  of  the  stomach.  That  is  a  purely  local  feeling,  referred 
in  a  former  part  of  this  lecture  to  the  local  nerves  ;  whereas  this 
indicates  a  general  feeling  of  morbid  lassitude  and  physical  in- 
capacity throughout  the  whole  body.  There  is  a  confusion  of 
ideas,  sometimes  an  unnatural  sleep,  sometimes  faintness,  irregu- 
lar nervous  action,  such  as  flushings  of  the  face,  palpitation  of 
the  heart,  fidgets,  twitchings,  or  cramp. 

As  I  said  before,  these  are  often  the  accompaniments  of  gas- 
tric mucous  flux,  but  at  the  same  time  they  often  exist  without 
it ;  and,  indeed,  almost  anybody  may  bring  them  on  by  getting 
very  tired  and  then  eating  largely.  If  vomiting  occurs,  you  see 
no  mucus  in  the  egesta,  but  simply  the  food  last  taken  unaltered 
in  quality  or  appearance.  Digestion  is  more  than  slow,  it  has 
completely  stopped. 


532  PAIN  IN  THE  STOMACH. 

Oppression  shows  an  exhausted  condition  of  the  muscular  and 
nervous  system  of  the  stomach.  The  peristaltic  motion  is  null 
from  want  of  power.  The  causes  usually  are  those  which  ex- 
haust the  nervous  energies  without  stimulating  the  powers  of 
life,  such  as  prolonged  and  severe  intellectual  labor,  annoyance 
of  mind,  and  overstrained  attention.  Temporarily,  and  in  per- 
sons previously  disposed,  mere  corporeal  exertion  may  bring  it 
on ;  but  this  form  of  depression  usually  works  its  own  cure,  and 
does  not  become  a  chronic  habit ;  for  the  excessive  bodily  toil 
either  causes  a  reactive  stage  of  increased  nutrition,  or  so  much 
exhausts  the  voluntary  muscular  system  that  it  cannot  be  con- 
tinued. 

This  view  of  the  pathology  of  the  disorder  obviously  suggests 
the  appropriate  treatment,  which  is,  to  tone  and  invigorate  the 
involuntary  muscles  of  the  stomach.  I  have  found  no  remedy 
do  this  so  invariably  as  strychnine.  Should  anaemia  be  present, 
iron — if  heartburn,  acidity,  or  waterbrash  be  joined,  then  bis- 
muth can  be  added  ;  but  where  the  symptom  named  exists  alone 
or  predominates  above  the  others,  still  more,  if  bark,  iron,  or 
other  tonics  in  any  way  disagree,  nothing  affords  such  satis- 
factory results  as  the  alkaloid  principle  of  nux  vomica  above 
named. 

Wearing  or  boring  vain  commences  gradually  soon  after 
food  ;  it  is  confined  to  the  epigastrium,  or  extends  itself  over 
the  abdomen,  and  does  not  run  up  the  oesophagus  like  heart-burn. 
It  sometimes  is  relieved  by  vomiting,  and  if  not,  continues  with 
more  or  less  intensity  till  the  stomach  empties  itself  through  the 
pylorus.  The  pain  is  increased  by  pressure,  very  often  not 
immediately,  but  in  the  course  of  a  minute  or  two,  as  if  the 
sluggish  sensation  of  the  part  took  some  time  to  appreciate  the 
injury. 

Boring  pain  is  nearly  always  sufficient  to  rouse  a  suspicion  of 
ulceration  ;  even  cancer  does  not  cause  it,  so  long  as  the  mucous 
membrane  be  whole.  The  suspicion  is  strengthened  if  weight 
and  tightness  of  epigastrium  be  present  to  indicate  the  excessive 
secretion  of  mucus  which  usually  accompanies  chronic  ulcer  ; 
and  the  diagnosis  is  further  confirmed  by  the  occurrence  of 
bloody  vomiting. 


PAIN  IN  THE  STOMACH.  533 

It  can  seldom  be  removed  by  internal  remedies.  Those  which 
do  it  most  good  are  bismuth,  opium,  and  kino ;  but  counter- 
irritants  to  the  external  surface  of  its  seat,  leeches,  blisters,  con- 
tinuous poultices,  mercurial  and  opiate  inunctions,  are  of  much 
more  marked  benefit. 

It  is  in  these  cases  especially  that  the  failing  organ  requires 
to  be  spared  work.  The  best  dietetic  substance  is  milk  made 
alkaline  with  lime  or  soda-water,  given  in  small  quantities  as 
frequently  as  possible.  Next  to  that,  a  mouthful  of  mutton 
chop  at  a  time,  with  a  dose  of  pepsine  to  digest  it.  Meals  are 
painful,  your  patient  tells  you,  so  advise  none  to  be  taken,  but 
a  continuous  sparing  supply  of  such  food  as  may  pass  through 
the  stomach  without  distending  it,  and  be  digested  by  the  small 
trickling  of  peptic  juice  which  there  is  in  the  stomach  and 
bowels.  The  chief  object  of  the  lime-water  is  to  prevent  the 
milk  forming  a  large  curd,  but  it  also  may  be  a  sedative  to  the 
raw  surface,  just  as  it  is  to  blistered  or  burnt  skin. 

Cramp  or  spasmodic  pain  in  the  epigastrium  appears  to  arise 
from  the  pyloric  sphincter.  It  is  often  accompanied  by  cramps 
in  the  neighboring  and  remote  muscles,  thus  affording  an  indi- 
cation of  the  tissue  in  which  its  seat  is  to  be  looked  for.  It 
occurs  chiefly  in  old  persons,  during  the  latter  period  of  the  stay 
of  the  food  in  the  stomach,  and  does  not  show  any  organic  dis- 
order of  the  part.  A  moderate  dose  of  an  anaesthetic  stimulant 
is  the  best  mode  of  relief :  the  domestic  remedy  of  a  thimbleful 
of  brandy  with  two  drops  of  laudanum  is  about  the  most  efficient 
that  can  be  administered. 


LECTURE    XLIV. 

ERUCTATION    AND    VOMITING. 

Anatomy  and  physiology  of  Eructation — Analysis  of  gases — 
deductions  therefrom — Defective  ahsorption — Decomposition  of 
food — Fermentation  preve7ited  by  acidity — Classification  of 
morbid  states  in  ivhich  eructation  occurs — Indications  of  treat- 
ment in  several  classes — Voiniting — Causes  of — Indications 
afforded  by  the  contents  of  the  vomit — Remedies  for — Possibil- 
ity of  starvation  from  vomiting  of  a  purely  functional  charac- 
ter— Sea-sickness  and  its  remedies. 

[Extra  course,  St.  Mary's,  Summer  Session,  1857.) 

In  considering  the  subject  of  eructation  it  must  be  remarked 
that  gaseous  contents  of  the  hollow  viscera  are  differently  cir- 
cumstanced from  liquids  and  solids  ;  their  great  expansibility  by 
heat,  and  their  low  specific  gravity,  give  them  an  inherent  force 
which  enables  them  to  find  their  way  out  without  any  aid  from 
the  muscular  system.  There  is  no  fluid  so  light  but  it  requires 
the  action  of  the  expiratory  muscles  to  expel  it,  Avhereas  no  gas 
is  so  heavy  but  that,  when  warmed  by  the  body,  it  will  not  rise 
through  the  oesophagus  directly  that  tube  is  relaxed. 

The  first  condition  of  eructation  is  the  relaxed  and  open  state 
of  the  cardiac  end  of  the  gullet.  The  air,  instead  of  being  re- 
tained by  the  contraction  of  this  powerful  sphincter,  finds  its  way 
upwards  in  greater  or  less  quantity.  The  passage  of  the  bubble 
towards  the  mouth  almost  always,  except  in  completely  paralytic 
patients,  causes  a  reaction,  and  by  the  time  it  gets  to  the  fauces 
it  is  compressed  by  the  stimulated  muscles,  and  expelled  with 
considerable  force.  Hence  the  noise  is  greater  than  is  caused 
by  the  mere  bubbling  of  air  up  the  gullet,  such  as  you  produce 


ERUCTATION  AND  VOMITING.  535 

in  moving  a  dead  body.  There  is  a  compound  of  relaxation  and 
reactionary  sj)asm,  the  former  taking  the  initiative. 

The  analyses  of  the  gas  contained  in  the  stomach,  by  Chevreul 
and  Chevillot,  show  that  more  than  four-fifths  of  it  is  atmos- 
pheric air  and  the  rest  carbonic  acid  in  much  less  proportion 
than  in  the  breath  which  is  passing  out  of  the  mouth  by  expira- 
tion. So  that  we  have  not  far  to  seek  for  a  source  of  the  air  ; 
it  is  evidently  swallowed  with  the  food  and  saliva  in  the  majority 
of  cases.  Some  persons  also  have  a  trick  of  half-consciously 
swallowing  air,  like  crib -biting  horses,  especially  when  suffering 
from  some  uneasiness  in  the  digestive  organs  ;  and  in  the 
paroxysms  of  sobbing,  of  hysteria,  and  of  epilepsy  large  quanti- 
ties are  gulped  down.  Gas  also  may  be  secreted  by  the  mucous 
membrane. 

Another  morbid  condition  that  produces  a  collection  of  gases 
is  defective  absorption.  In  health  gases  are  readily  absorbed 
by  the  alimentary  canal.  It  is  normal  for  the  abdomen  to  be 
dilated  during  digestion  with  several  pints  of  air,  which  disap- 
pear in  a  short  time  without  passing  upwards  or  downwards. 
To  be  convinced  of  this  fact  you  have  only  to  observe  the 
extent  to  which  the  parietes  of  the  belly  are  distended  and  the 
descent  of  the  diaphragm  is  impeded  after  even  a  light  meal  of 
only  a  few  cubic  inches  of  victuals.  In  an  hour  or  so  the  dis- 
tention has  all  gone,  without  making  any  sign  of  sudden  depar- 
ture, in  a  healthy  person.  But  in  an  invalid  body  absorption 
is  not  so  active ;  the  gas  normal  to  digestion  is  not  taken  up, 
and  remains  to  disturb  the  patient  by  its  continued  presence. 
Should  the  oesophagus  be  in  its  natural  state — that  is  to  say, 
equally  contracted  throughout — the  aerial  contents  of  the 
stomach  may  be  passed  on  through  the  pylorus,  to  produce  the 
state  of  flatulence,  which  will  be  considered  in  a  future  lecture. 
Should  that  tube  be  relaxed,  then  they  break  upwards  in  eruc- 
tations. 

So  far,  the  bulk  of  air  swallowed  has  been  supposed  to  be 
increased  only  by  heat  and  expansion.  But  in  some  cases  it 
is  further  augmented  by  gases  disengaged  from  decomposed 
food.     The  occurrence  of  alcoholic  fermentation  in  the  digestive 


536  ERUCTATION  AND  VOMITING. 

canal  is  proved  by  instances  of  vomiting,  in  which  the  matters 
ejected  are  visibly  undergoing  this  chemical  change.  They  are 
tumid  with  carbonic  acid,  like  yeasty  beer.  You  have  lately 
seen  a  man  in  Cambridge  Ward  in  whom  this  condition  of  the 
ejecta  was  conspicuous.  Half  a  pint  of  his  vomit,  left  to  stand, 
frothed  up  and  ran  over  the  edge  of  a  vessel  holding  two  quarts. 
You  may  imagine  what  a  disturbance  in  the  stomach  all  this 
must  make,  and  are  not  surprised  at  the  ejection  of  such  a 
turbulent  guest. 

Fortunately  the  spread  of  alcoholic  fermentation  through  the 
saccharine  contents  of  the  stomach  is  a  rare  occurrence.  Its 
features  are  so  marked,  and  the  discomfort  it  causes  so  great, 
that  we  should  hear  more  about  it  were  it  common.  The  fact 
is,  that  even  where  it  begins  and  gives  rise  to  the  disengage- 
ment perhaps  of  some  carbonic  acid,  it  is  rapidly  stopped  by 
the  conversion  of  the  sugar  into  lactic  acid,  a  fermentation 
more  congenial  to  the  temperature  of  the  body.  So  that  the 
"  acidity,"  which  in  a  former  lecture  has  been  spoken  about  as  an 
evil,  is  the  guardian  against  a  still  more  serious  evil. 

It  will  be  seen,  from  what  has  gone  before,  that  the  morbid 
states  of  which  eructation  is  a  phenomena,  naturally  arrange 
themselves  into  three  groups — (1)  where  there  is  simply  a 
relaxed  oesophagus,  (2)  where  there  is  an  increased  quantity  of 
atmospheric  air  swallowed,  and  (3)  where  foreign  gases  are 
formed  from  chemical  decomposition. 

In  the  first  may  be  included  many  cases  of  heartburn.  The 
quantity  of  air  brought  up  is  small,  but  it  relieves  discomfort, 
probably  by  stimulating  the  organ  to  contract — as  moving  a 
cramped  limb  cures  spasm.  It  may  be  observed  that  these 
cases  are  made  much  worse  by  motion.  I  have  been  told  by 
several  patients  that  if  they  kept  quiet  after  a  meal  they  experi- 
enced scarce  any  inconvenience,  whilst  exercise  invariably 
brought  on  eructations,  hiccough,  or  heartburn.  Sometimes  the 
eructations  are  the  prominent  symptom,  and  the  heartburn  is 
slight. 

Under  the  same  category  may  be  classed  cerebral  diseases, 
where  the  partial  loss  of  power  in   the   oesophagus  frequently 


ERUCTATION  AND  VOMITING.  537 

causes  eructations ;  in  which  instances  they  usually  occur  soon 
after  meals,  and  have  very  little  explosive  character. 

In  the  second  group  come  hysteria,  epilepsy  and  chorea. 
AYatch  an  hysterical  or  epileptic  fit,  and  you  will  see  great 
gulps  of  air  bolted  down.  In  chorea,  too,  you  may  often  detect 
by  the  eye  or  hand  an  involuntary  spasm  of  the  gullet,  which 
gulps  whether  any  solid  matter  is  present  or  not.  The  spasm 
of  the  oesophagus  in  hysteria,  called  globus  hystericus,  is  well 
known.  And  less  marked  manifestations  of  the  same  pheno- 
menon, uncomplained  of  by  the  patient,  or  called  simply  "heart- 
burn," occur  constantly  during  the  day,  and  fill  the  stomach 
with  air. 

The  excessive  swallowing  of  air  is  often  associated  with  a 
large  or  dilated  stomach,  but  I  cannot  satisfy  myself  whether 
it  is  cause  or  efi"ect ;  I  am  inclined  to  think  the  latter,  for  the 
following  reason  :  you  find  these  dilated  stomachs  principally 
as  the  result  of  some  mechanical  pressure  or  drag  on  the  organ 
from  without  ;*  and  therefore  I  do  not  know  whether  repletion 
from  within  alone  would  cause  a  permanent  increase  of  area, 
more  especially  repletion  with  a  substance  so  easily  got  rid  of 
as  air ;  while,  at  the  same  time,  it  is  easy  to  imagine  that  a 
large,  heavy  empty  stomach,  dragging  upon  the  cardia,  should 
give  rise  to  an  instinctive  gulping. 

In  this  class  of  cases,  the  explosions  of  air  occur  at  various 
times,  but  most  markedly  and  most  inconveniently  immediately 
on  swallowing  food  or  drink.  The  air  thrown  up  has  little  or 
no  taste  or  smell. 

In  the  third  group,  where  the  gas  is  really  generated  in  the 
alimentary  canal,  the  eructations  occur  much  later  after  eating — 

*  lu  13  cases  of  dilated  stomach  which  1  have  notes  of — 

3  had  gastric  cancer  (St.  George's  post-mortem  book) ; 
2  had  chronic  ulcer  (ditto)  ; 

2  had  dropsy  and  diseased  liver  (ditto)  ; 

1  had  ulcerated  oesophagus  and  distorted  ribs  (St.  Mary's  post-mortem 

book) ; 
1  has  a  pendulous  tumor  attached  to  the  pylorus  (alive)  ; 

3  have  very  fat  omenta  dragging  down  the  stomach  (alive) ; 
3  have  albuminuria  (alive). 


538  ERUCTATION  AND  VOMITING. 

sometimes  not  till  the  time  -when,  normally,  the  stomach  ought 
to  be  empty ;  and  if  they  do  come  close  upon  the  meal,  they 
continue  much  longer,  and  do  not  give  the  apparent  relief  which 
is  experienced  in  the  other  cases. 

The  gases  thus  eructated  are  nauseous  and  fetid,  sometimes 
with  the  odor  of  sulphuretted  hydrogen. 

In  these  cases  there  is  almost  always  mucous  flux  of  the 
stomach,  sometimes  from  anatomical  changes  in  some  part  of 
the  organ,  sometimes  without.  The  rationale  appears  to  be, 
that  organic  matters  in  a  state  of  decomposition  remain  adherent 
in  the  mucus,  and  act  as  ferments  to  the  newly  received  food. 
Perhaps,  too,  the  mucus  itself  may  decompose.  You  know  how 
quickly  that  takes  place  in  urine,  and  how  soon  its  decomposi- 
tion is  communicated  to  the  rest  of  the  fluid  in  or  out  of  the 
body  ;  and  the  same  is  likely  enough  to  happen  in  the  alimen- 
tary canal.  The  decomposition  of  the  mucus  is  confirmed  by 
the  frequency  Avith  which  different  sorts  of  low  organic  growths 
(moulds)  are  found  it  it.  The  cryptogam  sarcina  ventriculi  is 
the  most  distinctly  marked  of  these,  and,  though  detected  occa- 
sionally elsewhere,  certainly  finds  its  most  congenial  home  in 
the  stomach.  In  other  places  it  has  been  found  a  floating 
wanderer  in  fluids,  but  in  the  mucous  membrane  of  the  stomach 
it  ma}^  be  seen  fixed  and  growing  in  the  mucus.  It  is  not  often 
that  an  opportunity  occurs  of  proving  to  the  eye  that  such  is 
the  habitat  of  the  sarcina — we  frequently  find  it  vomited,  but 
the  patients  seldom  die  during  their  illness,  the  complaint  not 
being  a  fatal  one.  One  such  rare  opportunity  offered  itself 
two  years  ago,  in  a  girl  of  thirteen,  who  died  in  this  hospital  of 
enlarged  heart.  She  had  frequent  attacks  of  mucous  vomiting 
without  sarcinse  a  few  weeks  before  death,  and  at  the  autopsy 
we  found  the  seemingly  healthy  great  curvature  of  the  stomach 
thickly  clothed  with  a  stringy  mucus,  very  difficult  to  detach, 
in  the  outer  layer  of  which  a  great  quantity  of  sarcinixi  were 
imbedded. 

Being  fixed  thus  in  a  permanent  home,  as  shown  by  the  above- 
quoted  rare  case,  and  rapidly  replacing  with  new  growths  those 
which  are  wiped  away  by  the  food,  the  sarcinse  is,  unfortunately, 


ERUCTATION  AND  VOMITING.  539 

by  no  means  idle.  A  great  number,  perhaps  all,  of  those  cryp- 
togamous  plants  whose  nature  is  to  grow  upon  decomposing 
organic  matter,  have  the  property  of  promoting  decomposition, 
so  that  they  are  not  only  the  consequences,  but  the  causes  also 
of  decay.  It  is  found  that  the  gutta-percha  covering  to  electric- 
telegraph  wires,  when  laid  down  near  the  roots  of  oaks,  becomes 
rapidly  rotten  from  the  presence  of  a  fungus  peculiar  to  that 
tree.  Put  jam  in  a  new  cupboard,  and  it  will  keep  much  longer 
than  in  an  old  one,  where  mould  has  previously  grown.  Econo- 
mical housewives  have  sometimes  what  they  call  a  "  vinegar- 
plant  ;"  it  is,  as  I  show  you  here,  a  fungoid  vegetable  found  in 
vinegar  casks.  If  placed  in  sugar  and  water,  it  makes  the 
whole  undergo  the  acetous  fermentation  in  two  or  three  weeks, 
instead  of  the  process  occupying  several  months.  The  mould 
found  in  yeast,  the  torula  cerevisige,  though  not  essential  to 
alcoholic  fermentation,  certainly  augments  the  rapidity  of  its 
induction ;  so  that  it  is  entirely  in  accordance  with  known  phy- 
sical laws  if  the  presence  of  sarcinse,  or  of  the  yeast-plant,  on 
the  mucus  of  the  stomach  should  bring  on  fermentation  in  the 
food  before  the  obstructed  absorbents  have  time  to  take  it  up. 
Both  have  been  found  in  the  contents  of  the  stomach  ejected; 
and  it  is  shown  by  the  case  I  quoted,  that  sarcinge  at  least  may 
exist  adherent  to  the  mucus  without  being  thrown  up.  Probably 
very  often  these  plants  are  unseen  promoters  of  the  rapid  fer- 
mentation which  takes  place  so  mysteriously  in  the  stomach  of 
invalids. 

Besides  producing  eructation,  the  fermenting  of  organic 
matters  in  the  stomach  is  almost  always  followed  by  vomiting  ; 
while,  if  it  takes  place  in  the  bowels,  the  consequence  is 
diarrhoea ;  two  phenomena  which  will  be  considered  shortly  in 
their  own  place. 

The  indications  of  treatment  afforded  by  eructation,  are  differ- 
ent in  the  three  groups  of  cases  in  which  it  occurs.  In  the  first, 
antacids  are  often  sufiicient  for  temporary  relief.  Four  grains 
of  rhubarb-pill,  with  a  grain  of  gallic  acid,  taken  before  dinner, 
will  be  found  still  more  useful,  for  the  tone  thus  given  to  the 
mucous  membrane  prevents  the  recurrence  of  the  inconvenience. 


540  ERUCTATION  AND  VOMITING. 

In  more  severe  cases  I  have  found  a  rhubarb  draught  witli  gallic 
acid,  taken  three  times  a  day,  a  very  efficient  remedy. 

In  the  second  group  (where  excess  of  air  is  swallowed)  valerian 
and  ammonia  are  very  beneficial.  Where  there  is  nausea  or 
vomiting,  the  valerianate  of  zinc  may  take  their  place ;  but  it  is 
not  so  certain  as  the  infusion  or  tincture  of  the  herb.  Where 
this  fails  use  strychnine,  which  you  have  occasionally  seen  in 
the  wards  to  be  a  most  powerful  means  to  steady  temporarily 
such  irregular  nervous  action  as  hysteria,  chorea,  &c.,  though  it 
does  not  effect  a  permanent  cure,  like  iron  and  arsenic. 

In  the  third  group,  the  great  object  must  be  to  prevent  de- 
composition. In  the  laboratory  you  find  that  no  agent  is  so 
powerful  in  this  respect  as  sulphurous  acid;  and,  accordingly,  it 
is  much  used  in  various  processes  of  the  arts  for  the  purpose. 
Sulphur  is  often  burnt  in  casks  to  arrest  the  fermentation  which 
is  apt  to  be  going  on  in  the  liquids  soaked  up  by  the  cracks  or 
porous  parts  of  the  wood,  and  the  sulphurous  acid  vapors  eflFec- 
tually  do  their  duty.  The  Board  of  Health  finds  no  disinfectant 
for  fetid  sewers  so  instantaneous  in  its  action  as  Macdougal's, 
the  chief  ingredient  in  which  is  sulphite  of  lime.  Meat  may  be 
prepared  on  the  same  principle,  and  keeps  as  well  as  when 
salted  or  dried;  and  you  may  test  even  on  such  a  delicate 
substance  as  yelk  of  egg  how  fresh  it  keeps  with  any  sulphite 
salt.  The  same  efi"ect  is  produced  by  taking  as  a  medicine 
hyposulphite  of  soda;  the  fermentation  of  the  contents  of  the 
stomach  is  arrested,  and  the  evil  effects  of  that  fermentation 
prevented. 

Another  powerful  arrester  of  chemical  changes  is  charcoal. 
When  soup  has  begun  to  turn  sour  in  hot  weather,  clever  cooks 
boil  it  again  with  a  little  bag  of  charcoal  in  it,  and  it  becomes 
quite  sweet.  The  same  agent  will  prevent  decomposition  in  the 
alimentary  canal.  I  have  used  it,  I  must  say,  only  in  cases 
where  decomposition  occurs  in  the  intestines,  producing  flatu- 
lence; but  I  should  not  hesitate  to  employ  it  in  gastric  fermen- 
tation also,  if  hyposulphite  of  soda  chanced  to  disagree  or  was 
not  beneficial. 

Vomiting  seems  less  than  any  of  the  phenomena  previously 


ERUCTATION  AND  VOMITING.  541 

discussed  dependent  upon  the  peculiar  condition  of  the  stomach, 
and  more  upon  the  idiosyncracy  of  the  individual.  There  are 
those  who,  whatever  may  be  the  matter  with  them,  never  vomit ; 
while  others  do  so  on  the  slightest  occasion.  Even  pleasant 
associations  will,  in  some  people,  bring  on  this  most  unpleasant 
consequence:  a  patient  of  mine,  a  healthy  young  lady,  is  fre- 
quently seized  with  retching  on  entering  a  ball-room  where  she 
expects  an  agreeable  evening.  On  the  other  hand,  I  have  had 
patients  with  cancer  of  the  stomach,  and  others  with  various 
sorts  of  severe  dyspepsia,  who  could  take  the  most  nauseating 
medicine  without  inconvenience.  The  mere  fact  of  vomitinof, 
therefore,  affords  in  itself  no  clue  to  the  local  condition  of  the 
stomach.  But  the  time  of  its  occurrence,  the  circumstances 
which  increase  it,  and  the  nature  of  the  matters  thrown  up,  may 
be  most  suggestive  to  the  practitioner. 

Vomiting  which  occurs  when  the  stomach  is  empty,  or  which, 
though  it  occurs  at  other  times,  is  most  frequent  and  distressing 
then,  may  be  safely  set  down  as  arising  not  from  any  fault  of 
the  viscus  itself.  Such  is  the  morning  vomiting  frequent  in 
pregnant  women,  in  cases  of  diseased  heart,  of  abdominal 
tumor,  and  sometimes  of  pulmonary  consumption.  This  is  no 
doubt  a  reflex  action  of  the  vagus  nerve  excited  by  the  irregular 
irritation  of  some  of  its  branches;  and  on  the  same  principle  I 
can  easily  understand  the  more  rare  cases  where  vomiting  has 
been  caused  by  foreign  bodies  in  the  ear  or  nose,  by  tumors  in 
the  neck,  &c. 

When  vomiting  occurs  with  a  replenished  stomach,  it  may  be 
considered  as  a  general  rule  that  the  smaller  the  quantity  of 
food  that  produces  it,  and  the  sooner  it  takes  place  after  eating, 
the  nearer  to  the  mouth  is  the  seat  of  injury.  Disease  of  the 
oesophagus  causes  rejection  of  the  food  before  it  has  got  down; 
of  the  cardia,  or  smaller  curvature,  very  soon  after  it  has  got 
down;  and  disease  of  the  pylorus,  or  pancreas,  or  liver,  after  an 
interval  sometimes  of  as  much  as  several  hours. 

When  vomiting  arises  from  congestion  of  the  brain,  as  in 
apoplexy,  drowning,  concussion,  or  in  dead  drunkenness,  it  is 
increased  by  the  horizontal  posture;  when  it  arises  from  deficient 
35 


542  ERUCTATION  AND  VOMITING. 

supply  of  blood,  as  in  fainting,  anaemia,  and  sea-sickness,  that 
position  relieves  it. 

The  contents  of  the  vomit  which  can  afford  practical  sug- 
gestions to  the  practitioner,  are  the  following: 

Mucus,  if  it  is  in  large  stringy  masses,  shows  a  generally  dif- 
fused morbid  condition  of  the  stomach  itself;  if  it  is  in  small 
round  lumps,  it  has  most  probably  been  secreted  from  the  bronchi 
and  swallowea. 

Blood,  when  it  comes  from  an  open  vessel  perforated  by  an 
ulcer,  always  is  in  considerable  quantities,  and  contains  black 
clots;  if  it  is  mixed  up  with  mucus,  brown  and  shreddy,  it 
denotes  a  high  state  of  congestion  of  the  gastric  walls,  with 
rupture  of  some  small  capillaries,  or  what  is  commonly  called 
"exudation," 

Saliva,  readily  distinguished  by  its  alkalinity,  and  the  abun- 
dance of  buccal  epitelium  contained  in  it ;  when  in  large 
quantities,  it  denotes  an  irritable  state  of  oesophagus  and  fauces ; 
when  it  constitutes  the  bulk  of  the  vomit  of  pregnant  women, 
you  will  often  find  associated  with  it  a  sort  of  salivation  in  the 
mouth. 

Fseces  or  fseculent  smell.  This  is  usually  referred  to  a  reversal 
of  the  peristaltic  motion;  but  I  do  not  think  it  necessary  to 
resort  to  such  a  strained  explanation.  When  we  reflect  that 
about  twelve  quarts  of  secretion  are  daily  poured  into  the  in- 
testines, it  is  easy  to  see  that  you  have  only  to  stop  the  onward 
peristaltic  wave  and  absorption,  for  the  ilia  to  get  overfilled 
and  for  their  contents  to  overflow  upwards  into  the  stomach. 
There  they  naturally  produce  vomiting,  just  as  they  would  if 
swallowed.  Such  a  paralysis  of  muscles  and  absorbents  takes 
place  in  peritonitis,  as  well  as  in  mechanical  obstruction  of  the 
ilia,  and  consequently  in  peritonitis  you  have  sometimes  faBculent 
vomiting. 

Fermenting  matters  in  the  vomit  show  the  continuous  reten- 
tion in  the  stomach  of  some  remains  of  the  food  or  of  vegetable 
growths  in  a  constant  state  of  chemical  change.  There  is  there- 
fore present  a  quantity  of  adherent  mucus  capable  of  retaining 
them  there. 


ERUCTATION  AND  VOMITING.  643 

Acid  matters  in  excessive  amount  may  arise  from  a  similar 
state  of  things;  but  it  seems  as  if  simple  torpidity  of  stomach, 
without  the  necessary  presence  of  mucus,  can  occasion  it. 

Pure  unchanged  food  shows  that  the  vomiting  arises  from  the 
state  of  the  nervous  system,  which  is  either  locally  irritable, 
from  neighboring  anatomical  changes;  or  secondarily,  as  in 
pregnancy ;  or  generally,  as  in  hysteria. 

The  remedies  which  I  have  found  most  useful  in  cases  of 
vomiting  are  the  following: 

Hydrocyanic  acid,  where  it  arises  not  from  any  fault  of  the 
stomach  itself,  but  from  the  secondary  condition  of  the  nervous 
system,  as  in  pregnancy,  diseased  heart,  and  abdominal  tumor, 
in  pulmonary  consumption,  in  peritonitis. 

Carbonate  of  magnesia,  in  the  vomiting  accompanying  gastric 
flux,  with  copious  formation  of  acid. 

Opium,  in  acute  vomiting  from  gastric  ulcer,  from  malignant 
tumor,  in  faecal  vomiting  from  perforation,  peritonitis,  internal 
hernia — in  short,  wherever  the  vomiting  is  accompanied  by  much 
local  pain. 

Chloroform,  in  the  vomiting  at  the  commencement  of  fevers. 
It  may  be  applied  either  on  a  cloth  to  the  epigastrium,  especi- 
ally in  choleraic  vomiting,  or  taken  by  the  mouth. 

Leeches.  Very  often  the  vomiting  in  cases  of  gastric  ulcer 
will  not  be  appeased  till  some  leeches  have  been  applied  to  the 
epigastrium. 

Milk  arid  lime-water,  as  a  sole  diet,  will  often  alone  stop 
chronic  vomiting.  Complete  rest  and  absence  from  excitement 
must  accompany  its  use. 

Brandy,  in  teaspoonful  doses,  is  a  favorite  domestic  remedy. 
It  is  suitable  in  acute  cases  for  the  nonce,  and  will  often  stop 
nervous  vomiting  from  mental  causes,  but  is  obviously  not  adapted 
for  chronic  disease. 

Creasote.  This  is  an  uncertain  remedy,  and  I  confess  I  cannot 
at  all  satisfy  myself  what  cases  it  is  suited  to.  The  vomiting  cer- 
tainly seems  checked  by  it  sometimes,  sometimes  is  aggravated, 
more  commonly  is  uninfluenced.  The  cases  where  it  has  done  good 
have  appeared  to  me  generally  dependent  on  nervous  causes.  For 
example,  it  has  been  beneficial  in  hysterical  vomiting. 


544  ERUCTATION  AND  VOMITING. 

Valerianate  of  zinc  I  tried  once  in  hysterical  vomiting  with 
good  effect.  But  in  these  patients  the  most  powerful  remedy  is 
the  shower-hath. 

Ice  is  often  most  useful  in  acute  vomiting  in  fevers,  in  chronic 
cases  of  gastric  ulcer,  and  in  all  cases  is  an  agreeable  remedy  in 
warm  weather. 

The  administration  of  food  in  cases  of  chronic  vomiting  is  a 
matter  of  much  importance.  You  must  not  let  your  patient  be 
starved.  Even  when  milk  and  lime-water  does  not  check  the 
vomiting,  it  is  by  far  the  best  diet.  In  teaspoonfuls  at  a  time, 
it  can  almost  always  be  kept  down. 

The  risk  of  being  starved  to  death  from  vomiting  is  not  an 
hypothetical  fear.  A  young  woman  came  under  my  care  at  this 
hospital  a  few  months  ago  who  had  been  deserted  by  her  lover. 
She  had  violent  hysteria,  and  an  utter  inability  to  keep  anything 
on  her  stomach  for  some  days  ;  the  pulse  was  failing,  and  the 
tongue  getting  dry  and  brown.  An  attempt  was  made  to  retain 
life  by  means  of  nutritive  enemata,  but  in  vain.  At  the  post- 
mortem examination  every  organ  was  in  a  completely  normal 
state,  and  the  catamenia  were  still  flowing  from  the  uterus.  She 
had  died  of  starvation  only. 

When  sea-sickness  goes  to  the  extent  of  making  a  person 
seriously  ill,  it  is  worth  while  to  stop  it  or  prevent  it,  as  you  can 
often  do  by  a  large  dose  of  opium.  But  it  is  very  far  from  being 
worth  while  for  healthy  persons,  or  even  invalids,  in  ordinary 
cases,  to  take  this  preventive ;  for  a  small  dose  is  useless,  and 
the  requisite  large  one  makes  the  patient  endure  much  more 
discomfort  afterwards  than  the  sickness  during  the  voyage  would 
have  caused.  Chloroform  does  not  arrest  the  nausea,  but  it 
certainly  does  seem  to  control  the  violence  of  the  straining. 
Effervescing  stimulants  are  the  most  effective  palliative  for 
healthy  persons.  In  some  rough  rolling  weather  off  the  coast 
of  Portugal  I  once  tried  on  myself  and  several  companions 
champagne  and  highly  devilled  biscuits  with  complete  success. 
But  the  panacea  is  not  always  accessible ;  the  best  imitation  of 
it  generally  at  hand  is  frothy  bottled  porter :  if  it  does  not  in 
■every  case  prevent  the  vomiting,  yet  the  prostration  afterwards 


ERUCTATION  AND  VOMITING.  545 

is  avoided,  and  the  ejecta  are  not  so  disagreeable  as  when  they 
consist  only  of  bile  and  acid  mucus.  Warmth  is  also  very  im- 
portant: landsmen  will  often  expose  themselves  as  much  as  pos- 
sible to  the  breeze,  thinking  that  the  freshening  air  will  revive 
them  and  keep  them  well.  This  is  a  great  mistake  ;  they  should 
clothe  themselves  as  warm  as  possible,  put  a  flannel  band  or 
faja  round  the  waist  and  abdomen,  and  above  all  things  keep  dry 
and  quiet,  and  when  they  feel  miserable,  go  and  sit  with  their 
backs  tojthe  funnel. 

Of  various  vaunted  specifics  my  only  experience  is  that  of 
ridiculous  failures,  which  might  make  you  laugh,  but  teach, 
nothing.* 

*  Since  this  was  written  I  have  come  across  a  case  where  a  martyr  to 
science  tried  the  experiment  of  putting  a  bag  of  ice  down  the  back  ;  but  the 
string  which  tied  it  round  the  neck  got  loose  and  considerable  discomfort 
accrued. 


LECTURE   XLY. 

DIARRH(EA. 

Pathology  of  diarrhoea — Difference  of  it  from  mere  frequency  of 
evacuation — Division  of  diarrhoeas — Bilious —  Watery — Muco- 
purulent— Bloody — Putrid — Their  causes  and  indications — 
Supplementary  and  reflex  diarrhoea — Infantile — In  fever — 
Ulceration  of  bowels — Mucous  flux — Copious  solid  matter — 
Acid  diarrhoea — Use  of  opium — Riding — Cautions  about 
traveling — Flatus  in  the  ilia —  Use  of  charcoal,  ^c. 

{Extra  course,  St.  Mary's,  Summer  Session,  1857.) 

When  the  absorbing  power  of  the  intestines  is  defective,  the 
consequence  is  an  excess  in  the  quantity  of  matters  -syhich  pass 
through  them  ;  that  which  ought  to  be  taken  up  is  carried  along 
with  a  normal  draught,  and  so  constitutes  a  true  diarrhoea. 

It  is  of  great  practical  importance  to  distinguish  this  from  the 
mere  frequency  of  evacuation,  which  is  quite  consistent  with  a 
natural  or  even  deficient  amount  of  faeces.  The  number  of 
motions,  or  the  number  of  times  an  inclination  is  felt  to  void 
them,  is  often  increased  when  less  than  the  average  quantity 
may  be  passed  in  the  twenty-four  hours.  This  is  of  the  nature 
of  tenesmus,  and  arises  from  an  abnormal  state,  sometimes  ulcer- 
ation, sometimes  piles,  sometimes  cancer  even  of  colon  or  rectum; 
whereas  true  diarrhoea,  as  aforesaid,  depends  upon  defective  func- 
tion of  the  ilia. 

The  arrest  of  function,  as  declared  by  the  prevailing  contents 
of  the  stools,  constitutes  the  best  principle  of  division  ;  and  ac- 
cording to  it  we  may  speak  without  being  misunderstood  of  crapu- 
lous, bilious,  serous,  dysenteric  diarrhoea,  and  cholera. 

Crapulous  diarrhoea  is  simply  an  excessive  quantity  of  food 


DIARRHGEA.  547 

taken,  or  arrested  in  its  normal  solution  by  suspension  of  the 
gastric  function.  It  is  called  crapulous,  because  it  is  most 
usual  after  a  debauch ;  but  in  weakly  persons  it  is  not  necessary 
that  the  intemperance  should  be  absolute  ;  that  which  is  mode- 
ration for  others  may  be  an  excess  in  them.  An  examination 
of  the  faeces  exhibits  a  quantity  of  undigested  food  as  the  pro- 
minent feature,  sometimes  acid,  sometimes  fetid  and  fermenting, 
and  rarely  with  enough  bile  mixed  with  it  to  prevent  decompo- 
sition. 

Bilious  diarrhoea  is  the  next  simplest  form  of  the  disorder. 
Bile,  normally  poured  out  by  the  liver  to  the  extent  of  from 
three  to  four  pints  a  day,  if  not  concentrated  by  the  intestinal 
absorption,  adds  very  largely  to  the  quantity  of  excrement, 
where  its  presence  is  declared  by  its  well-known  smell,  and  by 
a  color  exhibiting  various  shades  of  yellow,  brown,  and  olive- 
green,  according  to  its  absorption  of  oxygen  and  mixture  with 
foeces. 

This  arrest  of  the  absorbing  powers  of  the  intestines  and  con- 
sequent rejection  of  bile  mixed  at  first  with  faeces,  and  when 
the  bowels  are  emptied  augmented  by  the  exudation  of  water 
from  their  parietes,  is  what  so  often  takes  place  temporarily  from 
the  impression  of  cold,  from  irritation  of  the  alimentary  canal 
by  unwholesome  food,  and  from  mental  emotion.  It  is  possible 
also  that  the  qualities  of  the  bile  itself  may  be  altered  in  some 
cases,  or  its  quantity  increased.  It  may  be  changed  by  medi- 
cines, as  by  calomel  or  by  senna,  and  so  rendered  incapable  of 
absorption,  and  be  poured  through  the  ilia  without  their  being 
in  fault.  Congestion  of  the  portal  system,  such  as  is  especially 
frequent  in  Europeans  resident  in  warm  climates,  causes  the  bile 
to  be  at  one  time  deficient,  and  afterwards  to  be  poured  out  in 
excess.  Irritation  of  the  stomach  and  duodenum  causes  it  to  be 
retained  in  the  liver  and  gall-bladder  till  it  is  unfit  for  absorp- 
tion. In  both  these  cases  it  is  rejected  by  the  bowels  and  con- 
stitutes bilious  diarrhoea. 

You  must  be  very  careful  to  distinguish  this  symptom  from  a 
different  one,  often  confounded  with  it — viz.,  the  presence  of  a 
bright  grass-green  matter  in  the  stools.      This  is  not  bile  at  all, 


548  DIARRHCEA. 

but  in  reality  altered  blood,  and  denotes  congestive  inflammation 
of  the  mucous  membrane,  a  state  requiring  very  opposite  treat- 
ment from  that  proper  for  bilious  diarrhoea.  Your  best  aids  to 
diacrnosis  are  first,  the  smell: — in  real  bilious  stools  the  odor  of 
the  hepatic  secretion  can  always  be  perceived,  in  spite  of  the 
fseces  mixed  with  it ;  and  at  the  same  time  it  always  prevents 
putrescence,  or  even  counteracts  the  incipient  putrescence  of  the 
undigested  aliments  ;  while  in  the  grass-green  stools  the  smell  is 
not  of  bile,  but  more  or  less  cadaverous  or  putrid.  Secondly — 
the  microscope  exhibits  in  the  riiucus,  which  always  is  present  in 
congestive  inflammation,  the  usual  globules  of  pus  mixed  with 
small  shreds  of  fibrine  and  blood-globules. 

In  serous  or  watery  diarrhoea  it  is  probable  that  there  is  an 
increased  exhalation  of  aqueous  fluid  from  the  blood-vessels  of 
the  intestines,  as  well  as  an  arrest  of  its  absorption.  In  this 
form,  when  pure,  if  the  faeces  are  retained  by  a  voluntary  eff'ort, 
they  may  be  concentrated  nearly  to  their  normal  condition  by 
the  removal  of  the  water,  and  thus  a  test  aff'orded  that  their 
state  depends  mainly  on  the  addition  of  this  constituent.  For 
that  which  can  be  so  readily  taken  up  again  into  the  blood  can- 
not be  of  a  nature  very  foreign  to  it.  Thus,  for  instance,  if  you 
take  a  saline  purgative,  you  may  feel  several  pints  of  fluid  roll- 
ing about  in  the  bowels;  but  if  you  resist  the  inclination  to  stool, 
it  goes  off  at  last,  and  you  void  afterwards  little  more  than  the 
ordinary  amount  of  semi-solid  fgeces.  It  is  not  so  in  bilious  or 
inflammatory  diarrhoeas. 

Watery  diarrhoea,  when  not  arising  from  the  anti-osmotic 
action  of  neutral  salts,  indicates  a  congested  state  of  the  venous 
plexus  of  the  alimentary  canal,  and  a  consequent  morbid  prone- 
ness  to  exhalation  and  deficiency  in  absorption.  The  vitality 
of  the  mucous  membrane  is  deficient;  and  if  it  is  not  restored, 
local  death,  exhibited  in  the  form  of  ulcers  and  sloughs,  must  be 
the  result. 

The  exhalation,  however,  tends  to  become  habitual,  and  so 
continues  beyond  the  period  of  congestion,  so  that  the  whole 
mass  of  blood  is  relieved  of  its  water,  and  in  this  way  sometimes 


DIARRHCEA.  549 

dropsical  swellings  may  be  re-absorbed  and  pass  off  through  the 
bowels. 

In  dysenteric  or  mueo-purulent  diarrhoea,  water  is  in  excess, 
but  the  characteristic  is  in  the  presence  of  mucus  or  pus  mixed 
"with  it;  in  which  also  there  are,  in  cases  seen  early,  shreds  of 
fibrin,  blood-globules,  and  flakes  of  the  peculiar  epithelium  of 
the  bowels. 

Should  any  of  these  products  of  inflammation  be  alone,  sepa- 
rate and  unmixed  with  faeces,  then  it  is  probable  they  come  from 
the  colon  or  rectum;  but  if  they  are  mixed  up  with  a  large  quan- 
tity of  watery  fluid,  and  still  more,  if  that  watery  fluid  shows 
itself  to  be  the  serum  of  the  blood  by  coagulating  with  heat,  then 
there  is  little  doubt  of  their  source  being  the  mucous  membrane 
of  the  ilia,  whose  morbid  condition  it  consequently  indicates. 
The  fluid  in  muco-purulent  diarrhoea  is  always  highly  alkaline, 
and  if  it  is  examined  with  the  microscope,  crystals  of  ammonio- 
magnesian  phosphate  are  found  scattered  through  it.  If  allowed 
to  stand,  it  separates  into  two  distinct  parts:  the  one  serous, 
varying  in  color  from  complete  whiteness  and  transparency 
through  all  the  shades  of  yellow  to  deep  brown ;  or,  where  blood 
is  present,  to  red  and  black,  in  which  are  the  flakes  of  fibrin, 
the  ammoniacal  crystals,  and  floating  globules ;  the  other  sedi- 
mentary,  consisting  principally  of  gray,  granular  matter,  the 
debris  of  food  mixed  with  more  or  less  of  the  coloring  matter  of 
the  bile  and  half  digested  blood. 

The  degree  of  serosity  and  the  proportion  of  the  products  of 
inflammation  in  the  first,  show  the  extent  to  which  inflammation 
has  gone  in  the  mucous  membrane ;  whiteness,  bloodiness, 
putridity,  alkalinity,  being  bad  signs;  yellowness,  opacity,  the 
smell  of  bile,  and  the  absence  of  putridity,  being  good. 

The  second,  or  sedimentary  portion  proves  the  condition  of 
the  general  system  rather  than  of  the  ilia  in  particular.  If  it 
is  copious  in  proportion  to  the  fluid,  then  the  normal  function  of 
destructive  assimilation  is  shown  to  be  little  interfered  with;  if 
it  is  scanty,  then  we  know  this  important  process  to  be  arrested, 
the  effete  morbid  tissues  are  not  being  removed  from  the  body, 
and  a  more  grave  state  of  affairs  exists.     The  quantity  of  solid 


550  DIARRHCEA. 

sedimentary  matter  is  the  best  test  you  can  have  of  an  advance 
towards  health,  or  departure  therefrom,  in  all  cases  where  there 
is  this  state  of  bowels. 

The  most  common  examples  of  muco-purulent  diarrhoea  are 
found  among  acute  diseases,  in  low  fever,  in  cholera,  enteritis, 
and  dysentery,  especially  in  the  teething  dysentery  of  children. 
Among  chronic  diseases,  ulceration  of  the  bowels,  whether  a 
consequence  of  phthisis  or  low  fever,  is  the  most  usual  cause. 

Bloody  diarrhoea,  where  the  blood  is  in  small  streaks  in  the 
mucus,  or  slightly  mixed  with  the  serum,  or  mixed  with  the 
grass-green  mucus  above  described,  indicates  a  recent  inflam- 
matory state.  When  it  is  in  clots,  either  black  or  fibrinous, 
with  the  globules  partially  washed  away,  it  shows  that  a  blood- 
vessel of  notable  size  has  been  opened  into,  probably  by  ulcera- 
tion. Should  pus  be  mixed  with  it,  the  diagnosis  of  ulceration 
is  confirmed.  Black,  semi-digested  blood,  precipitated  by  stand- 
ing with  the  sediment  of  fluid  stools,  comes  from  high  up  in  the 
alimentary  canal,  as  it  indicates  its  exposure  to  the  gastric  juice. 
It  not  unfrequently  comes  from  the  stomach  itself. 

Putridity  of  the  stools  in  diarrhoea  always  shows  that  there  is 
an  imperfect  quantity  of  bile  in  them,  one  of  the  most  clearly 
ascertained  functions  of  the  hepatic  secretion  being  to  prevent 
the  chemical  decomposition  of  albuminous  matters.  Putridity 
may  arise  from  two  sources — namely,  the  food  taken,  or  the 
albuminous  secretions  into  the  alimentary  canal.  A  close  ex- 
amination of  the  stools  will  generally  distinguish  one  from  the 
other.  If  it  is  non-digested  food  which  is  decaying,  then  the 
solid  constituents  of  the  faeces  are  bulky,  pale,  containing  large 
lumps  of  still  paler  substance  visible  to  the  naked  eye.  And 
if  these  are  examined  by  the  microscope,  they  will  be  found  to 
consist  of  muscular  fiber,  fat,  and  other  parts  of  victuals,  often 
swarming  with  live  infusoria  and  vibriones.  This  occurs  from 
time  to  time  in  all  cases  of  deranged  digestion.  If  the  fetor 
arises  from  the  decomposed  albumen  of  the  exhaled  serum,  it 
will  be  observed  to  be  exhaled  from  the  more  fluid  part  of  the 
motions,  which  are  like  the  washings  of  macerated  flesh,  while 
the  solid  part  is   scanty  and  comparatively  unaffected.     This 


DIARRIICEA.  551 

shows  a  much  more  serious  state  of  the  vital  powers,  and  in 
severe  complaints,  such  as  low  fever,  is  usually  the  harbinger 
of  death.  It  is  often  joined  to  a  peculiar  mouse-like  smell  in 
the  sweat. 

In  choleraic  diarrhoea  the  whole  mass  of  the  blood  is  poisoned, 
and  it  is  so  altered  in  its  physical  qualities  that  very  little  of  it 
remains  capable  of  supporting  life,  or  of  absorbing  the  where- 
withal to  support  life  either  in  the  shape  of  food  or  medicine. 
The  functions  of  the  liver  and  kidneys  are  suspended  for  want 
of  live  blood,  no  bile  appears  in  the  stools  or  vomit,  no  urine  in 
the  bladder. 

For  the  purpose  of  understanding  clearly  the  degree  in  which 
life  is  deficient  in  the  diiferent  forms  of  diarrhoea,  we  may  con- 
struct a  table  in  which  the  first  column  is  occupied  by  the  several 
functions,  the  loss  of  one  or  more  of  which  characterizes  those 
difi"erent  forms.  It  will  be  seen  that  the  sign  of  minus  may  be 
placed  against  one  after  the  other  till  the  normal  condition  of 
all  is  finally  lost,  as  an  essential,  not  accidental  part  of  the 
disease. 

(See  the  table  on  the  next  page.) 

In  some  instances  of  mucous  flux  and  indigestion  in  the  upper 
part  of  the  alimentary  canal,  the  stools  are  acid  from  time  to 
time.  There  is  nothing  special  in  the  pathology  of  this.  It 
arises  simply  from  so  much  acid  being  formed  from  the  decom- 
position of  food,  that  it  cannot  be  neutralized  by  the  alkaline 
juices.  Sometimes  the  acidification  takes  place  in  the  stomach, 
sometimes  in  the  caecum,  during  the  delay  of  the  decomposing 
aliments  there.  In  the  latter  case  considerable  pain  is  often 
experienced  in  the  right  iliac  region,  and  in  the  course  of  the 
colon  just  before  the  evacuations. 

In  all  forma  of  diarrhoea  from  affections  of  the  small  intestines 
the  evil  is  twofold;  first  the  aliment,  which  ought  to  contribute 
to  the  support  of  the  system,  is  hurried  through  the  abdomen, 
and  so  the  supplies  are  cut  off;  and  secondly,  destruction  is 
carried  on  at  an  increased  rate  by  exhalation  from  the  mucous 
membrane  of  the  bowels.     The  stick  is  being  cut  away  at  both 


552 


DIARRIICEA. 


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DIARRIICEA.  553 

ends,  and  hence  there  is  nothing  which  produces  such  rapid 
emaciation.  Where  so-caHed  "diarrhoea"  is  reported  to  you  as 
lasting  for  any  length  of  time  without  emaciation,  always  let 
your  suspicions  of  the  correctness  of  the  nomenclature  be  roused, 
and  observe  carefully  whether  the  quantity  of  excrement  be 
really  in  excess,  or  whether  the  ailment  have  not  rather  the 
nature  of  tenesmus,  and  arise  from  the  colon  or  rectum.  You 
will  generally  find  such  to  be  the  fact,  and  must  vary  your  treat- 
ment accordingly. 

Sometimes  diarrhoea  seems  to  be  the  transference  of  a  tendency 
to  exudation  of  serum  from  another  tissue  to  the  alimentary 
canal.  Such  is  that  which  sometimes  comes  on  of  its  own  accord 
or  may  be  artificially  induced  in  ascites,  and  which  certainly 
sometimes  diminishes  the  abdominal  collection.  Such  is  the 
diarrhoea  of  uraemia,  which,  however,  does  not  usually  relieve 
anasarca,  but  rather  increases  it  from  the  weakening  of  the  blood 
which  follows.  Hence  it  is  a  very  bad,  almost  a  fatal  symptom, 
in  the  latter  disease. 

The  most  important  indication  of  treatment  is  connected  with 
the  diet.  It  must  be  such  as  does  not  require  a  perfect  state  of 
the  digestive  organs  for  its  absorption,  while  at  the  same  time 
it  is  nutritive  to  the  patient.  The  best  of  all  is  milk  and  lime- 
water.  In  feverish  cases  it  may  be  iced,  and  soda-water  may  be 
occasionally  substituted  for  the  lime.  Keeping  a  person  solely 
on  this  diet  is  often  sufficient  alone  to  cure  all  sorts  of  diarrhoea 
not  dependent  on  a  permanent  chronic  cause;  and  even  where 
there  is  such  a  cause  for  it,  very  great  temporary  benefit  is  de- 
rived, which  forms  a  better  starting-point  for  medicinal  treatment 
than  the  previous  state. 

In  a  temporary  diarrhoea  without  other  disease,  the  loss  of  the 
normal  supply  to  the  body  is  not  of  so  much  consequence,  a  short 
starvation  perhaps  does  good  to  a  person  otherwise  healthy.  But 
in  severe  acute  disease,  or  in  long-continued  chronic  diarrhoea, 
this  is  an  important  consideration,  and  care  must  be  taken  to 
allow  for  it.  Since  food  in  the  usual  quantities  at  once  cannot 
be  borne,  and  is  rejected  undigested,  give  it  very  frequently  and 
in  small  portions.     The  alkaline  milk  diet  I  have  just  recom- 


554  DIARRHCEA. 

mended  allows  this  to  be  done  most  conveniently.  A  jug  of  the 
liquid  may  be  kept  close  at  hand,  and  sipped  from  time  to  time, 
so  that  as  much  nutriment  may  be  taken  in  the  twenty-four  hours 
as  would  be  done  by  a  healthy  person  without  the  alimentary 
canal  ever  being  overloaded. 

When  there  are  lumps  of  fseculent  matter  in  the  stools,  and  a 
smell  like  that  of  normal  excrement,  give  purgatives,  and  when 
there  is  no  normal  smell  present,  abstain.  For  it  is  only  the 
remains  of  previous  constipation  that  require  to  be  got  rid  of  in 
this  way,  and  when  they  are  not  present,  harm  is  done.  I  have 
known  cases  of  chronic  diarrhoea  much  injured  by  the  routine 
practiced  of  beginning  treatment  with  a  purge. 

Where  the  products  of  acute  inflammation  are  found  mixed  in 
the  stools,  such  as  white  and  opaque  mucus,  flakes  of  fibrin, 
epithelium,  blood-streaked  mucus,  bright  green  matter,  &c.,  as 
above  described,  leeches,  fomentations,  warm  hip-baths,  and 
poultices  to  the  abdomen,  are  appropriate  and  should  not  be  de- 
layed. In  the  case  of  babies,  the  whole  abdomen  and  loins  may 
be  fastened  up  in  a  large  circumambient  poultice,  which  they 
cannot  wriggle  away  from,  a  leech  put  on  near  the  naval,  and 
the  bite  allowed  to  bleed  for  a  little  time.  The  articles  of 
materia  medica  I  have  most  trust  in  are  calomel,  ipecacuanha, 
and  carbonate  of  soda.  Of  the  first  and  second  equal  quantities, 
and  a  double  quantity  of  the  third,  may  be  made  into  powders,  of 
which  from  four  to  six  grains,  according  to  the  child's  age,  may 
be  given  every  three  hours.  This  is  a  traditionary  powder,  but 
it  is  right  to  say  that  I  have  in  a  good  many  instances  lately  left 
out  the  calomel,  and  the  case  has  done  just  as  well  if  not  better 
without  it. 

Be  very  careful  in  infants  to  look  to  the  teeth.  The  state  of 
the  bowels  may  very  likely  be  dependent  on  reflex  irritation 
from  the  dental  nerves.  Lancing  the  gums  will  sometimes  stop 
a  most  violent  diarrhoea  where  the  stools  show  evident  proofs  of 
the  inflammatory  condition  of  the  ilia.  The  action  of  the  lanc- 
ing is  probably  much  the  same  as  that  of  leeches,  viz.,  a  relief 
to  the  congestion  of  the  mucous  membrane.  Upon  the  develop- 
ment of  the  teeth  themselves  it  can  hardly  be  supposed  to  have 


DIARRIICEA,  555 

any  influence,  but  that  it  alleviates  toothache  any  adult  can  ex- 
perience, on  himself,  though  it  is  diflScult  to  get  an  account  of 
the  action  of  the  remedy  from  his  little  patients. 

In  teething  infants  opium  is  of  striking  utility.  I  begin  with 
half  a  grain  of  Dover's  powder  every  three  hours,  increasing  the 
dose  by  half  a  gniin  every  three  hours,  till  a  decided  excess  of 
sleepiness  is  produced. 

But  there  is  no  doubt  that  the  most  important  cure  in  infan- 
tile diarrhoea  is  change  of  diet.  Bringing  up  by  hand  or  an  un- 
wholesome state  of  the  breast-milk  are  generally  at  the  bottom 
of  the  ailment.  No  remedy  is  equal  to  a  healthy  wet-nurse,  or 
where  circumstances  forbid  that,  as  near  an  imitation  as  can  be 
made  of  human  milk  by  that  of  animals,  such  as  the  old- 
fashioned  donkey's,  or  the  cow's  diluted  and  slightly  sweetened. 

In  low  fever  the  presence  of  diarrhoea  indicates  to  many  prac- 
titioners the  employment  of  mercury  in  the  form  of  mercury 
with  chalk.  The  effect  of  this  preparation  is  the  increase  of 
solid  sedimentary  matter  in  the  stools  ;  in  other  words,  a  re- 
storation of  the  destructive  assimilation  going  on  in  the  body. 
The  motions  are  diminished  in  number  and  in  fluidity,^  but  not 
in  actual  quantity.  Thus  the  tissues  devitalized  by  the  typhoid 
poison  are  removed,  and  can  be  replaced  by  new  nutriment. 
This  increase  of  solid  matter  is  taken  as  an  evidence  and  test 
of  benefit  accruing  from  the  use  of  mercury,  and  as  a  prognosis 
of  good.  But  I  confess  I  prefer  the  chalk  without  the  mercury  in 
the  shape  of  mistura  cretse,  or  the  employment  of  mineral  acids.  * 

Where,  in  the  absence  of  fever,  blood  is  passed  by  the  bowels, 
the  two  most  powerful  means  of  checking  it  I  have  found  to  be 
turpentine  and  acetate  of  lead,  especially  the  latter.  Its  direct 
influence  as  a  poison  on  the  bowels  would  have  led  to  an  expec- 
tation of  this.  If  the  hemorrhage  has  gone  on  for  some  time,  I 
am  inclined  to  think  it  must  be  sometimes  due  to  a  clot  distend- 
ing the  bowel,  and  preventing  it  contracting  upon  the  bleeding 
spot,  for  certainly  a  dose  of  castor-oil,  in  the  results  of  whose 
action  a  quantity  of  pale  clots  were  exhibited,  has  several  times 
in  my  experience  stopped  bleeding. 

*  Further  experience  has  confirmed  this  feeling. 


556  DIARRIICEA. 

The  long;  continuance  of  diarrhoea  from  ulceration  of  the  ilia 
must  starve  the  patient.  It  tends  also  to  prolong  itself;  for  the 
weaker  the  system  is,  the  more  irritable  are  the  sore  places,  and 
the  less  can  the  morbid  actions  they  set  up  be  resisted.  It  is 
right,  therefore,  to  use  direct  means  for  arresting  the  diarrhoea. 
The  best  are  such  as  blunt  the  sensibility  of  the  ulcerated  spots. 
The  milk-and-lime-water  diet  should  be  used  first,  then  chalk, 
and  opium,  which  appear  to  act  on  the  sore  mucous  membrane 
just  as  they  do  on  a  raw  blistered  surface  of  skin.  If  these  fail, 
sulphate  of  copper  should  be  used  in  doses  increased  from  a 
quarter  of  a  grain  up  to  two  grains. 

Where  there  is  a  simple  flux  of  transparent  mucus  without 
fever  or  pain  on  pressure,  and  no  fibrin  or  blood  in  the  mo- 
tions, the  vegetable  astringents,  such  as  logwood,  bark,  kino, 
and  tannin,  are  often  of  great  use.  In  such  cases,  too,  I  have 
prescribed  iron  with  seeming  benefit.  I  must,  however,  say, 
that  I  feel  doubtful  in  the  great  majority  of  instances  whether 
this  form  of  flux  is  not  rather  due  to  the  colon  than  to  the  small 
intestines. 

Where  the  solid  matter  is  copious,  pale,  and  fetid,  consisting 
mainly  of  undigested  food,  inspissated  bile  may  be  given  with 
benefit ;  the  stools  become  darker,  less  fetid,  and  less  frequent 
under  its  employment.  This  is  particularly  the  case  in  children 
whose  mesenteric  glands  are  diseased.  I  am  hopeful,  too,  that 
pepsine  will  prove  a  still  more  efficient  remedy  in  the  same 
cases,  as  it  certainly  diminishes  the  fetor  of  the  motions  in  the 
best  way — nam'ely,  by  promoting  the  normal  solution  of  the 
food. 

Acid  diarrhoea  indicates  the  free  employment  of  chalk. 

The  use  of  opiates  in  diarrhoea  must  never  be  made  a  matter 
of  routine.  As  a  general  rule,  I  have  found  them  beneficial 
without  consequent  harm  in  cases  where  there  was  tenesmus 
and  frequent  stools;  but  where  the  fasces  are  bulky  and  copious 
they  appear  to  impede  the  natural  secretion.  Where  the  stools 
also  are  putrid,  caution  is  required  in  their  use.  In  the  diar- 
rhoea which  so  often   accompanies  and  proves   fatal  in   ursemia, 


DIARRIICEA.  557 

they  check,  indeed,  the  debilitating  flux,  but  they  are  apt  to 
bring  on  coma. 

In  some  cases  of  diarrhoea  from  chronic  mucous  flux  of  the 
intestines,  without  ulceration  or  acute  inflammation,  I  have 
found  horse  exercise  serviceable.  I  suppose  it  is  the  gentle 
agitation  of  the  abdomen,  combined  with  the  air  and  amuse- 
ment, that  proves  of  use. 

In  recommending  the  recreation  of  travelin2  to  invalids  sub- 
ject  to  diarrhoea,  you  must  be  very  careful  of  the  route  you  se- 
lect. The  epidemic  influence  of  cholera  which  has  overspread 
Europe  during  the  present  generation,  visiting  almost  every 
square  mile  of  its  surface  several  times  during  the  last  fcAV  years, 
has  in  many  places  left  behind  it  a  chronic  endemic  poison.  The 
natives  are,  indeed,  insensible  to  it,  but  few  strangers  escape, 
becoming  aff"ected  more  or  less,  according  to  their  idiosyncrasies. 
Strong  persons  find  it  only  an  inconvenience,  but  an  invalid  is 
put  in  some  danger,  and  certainly  loses  all  the  advantage  of  the 
tour.  This  is  especially  the  case  in  the  mountainous  districts 
of  the  south  of  France,  the  Pyrenees,  and  Dauphiny,  and  in  the 
volcanic  regions  bordering  the  Rhine,  the  Eifel  and  Moselle 
country,  as  well  as  those  in  the  center  of  France,  the  ancient 
province  of  Auvergne.  All  these  places  are  attractive  from 
their  picturesque  beauties,  and  therefore  it  is  necessary  that  you 
should  be  warned  of  this  evil  attendant  upon  choosing  them 
as  the  scene  of  a  tour.  You  will  see  sometimes  the  whole  of  the 
strangers  at  a  table  d'hote  obliged  to  leave  the  room  at  once, 
and  cause  one  another  no  slight  inconvenience  by  tending  all 
together  in  the  same  direction ;  and  in  the  Pyrenees  I  have  seen 
powders  of  chalk-and-opium  packed  up  as  the  regular  concomi- 
tants of  a  day's  walk.  It  must  not  be  supposed  that  this  is  the 
result  of  the  foreign  modes  of  cooking.  I  have  known  English 
biscuits  and  porter,  and  boiled  eggs,  adopted  as  a  diet  without 
relief,  though  of  course  nothing  foreign  could  have  got  into 
them.  I  believe  the  cause  to  be  as  I  have  represented  it — 
namely  a  poison  left  endemic  since  the  passage  of  cholera 
through  the  country,  but  to  which  the  natives  have  become  ac- 
climatized. That  it  is  of  late  years  only  that  this  diarrhoea  has 
36 


558  DIARRHCEA. 

been  prevalent  is  shown  both  by  local  report  and  the  omission 
of  all  mention  of  it  from  the  well-knoAvn  work  on  "  Climate,"  by 
Sir  James  Clark. 

One  source  from  which  strangers  contract  this  diarrhoea  is  an 
evil  capable  of,  and  rightly  demanding,  amendment :  I  refer  to 
the  filthy  privies  in  continental  inns.  A  gentleman,  eminent  in 
his  profession  and  of  good  judgment,  told  me  that,  during  a 
Pyrenean  tour  lately,  he  entirely  escaped  the  diarrhoea  which 
everybody  else  without  exception  suffered  from,  by  adhering  to 
a  strict  rule  of  never  entering  one  of  these  disgusting  holes,  but 
worshipping  Cloacina  under  the  pure  light  of  the  stars.  Inva- 
lids and  ladies  cannot  so  well  manage  this  unless  they  are  rich 
enough  to  travel  with  carriages  and  servants  and  peripatetic 
Avater-closets. 

In  Italy  I  have  found  that  the  best  remedy  for  the  diarrhoea 
which  so  often  attacks  travelers  from  over-fatigue  in  summer 
and  autumn,  is  lemon-juice  and  the  horizontal  posture.  Lying 
down  for  a  couple  of  hours  on  the  back,  and  drinking  two  or 
three  glasses  of  strong  lemonade,  with  very  little  sugar,  gener- 
ally stops  it.  If  that  is  not  successful,  opium  must  be  had  re- 
course to. 

Flatus  in.  the  small  intestines  is  one  of  the  most  trouble- 
some forms  of  wind.  If  it  escape  into  the  stomach,  which  is 
fortunately  rare,  the  taste  and  smell  are  peculiarly  nauseous ; 
while  it  seems  to  have  considerable  difficulty  in  passing  the  ilio- 
C£ecal  valve.  Hence  it  rolls  about  in  the  abdomen  from  the 
changes  in  position  which  the  motion  outwards  of  the  alimentary 
masses  involve,  and  causes  the  well-known  and  distressing  "bor- 
borygmi,"  till  it  can  get  absorbed.  The  abdomen  will  often  be 
distended  for  several  days  with  it,  without  its  being  able  to 
escape. 

The  persons  most  liable  to  this  troublesome  affection  are  fat 
anaemic  and  hysterical  women  ;  it  follows  also  the  small  and  con- 
tracted liver  of  spirit-drinkers,  and  sometimes  is  very  annoying 
in  cases  of  dilated  heart.  Some  persons  in  apparent  health,  are 
habitually  much  troubled  with  it.  I  am  inclined  to  attribute  it, 
under  these  circumstances,  to  a  naturally  sluggish  portal  circu- 


DIARRHCEA.  559 

lation,  which  does  not  so  quickly  absorb  the  contained  air  as  a 
freer  current  through  the  blood-vessels  would  enable  it  to  do. 

Flatus  in  the  intestines  is  troublesome  during  the  day,  from 
the  tumidity  of  the  abdomen,  and  noise  on  motion,  and  pain  in 
the  side ;  but  when  it  comes  at  night  it  causes  still  more  incon- 
venience by  preventing  sleep.  I  cannot  explain  why  this  is ; 
there  is  not  enough  pain  or  discomfort  to  account  for  it,  yet  a 
complete  wakefulness  and  apparent  want  of  desire  for  sleep  com- 
monly prevails.  It  is  to  be  remarked,  also,  that  it  is  in  most 
instances  made  worse  by  opium.  Sometimes  the  patient  will  go 
to  sleep  easily  and  naturally  on  first  lying  down,  and  will  then 
wake  up  in  an  hour  or  two,  finding  his  abdomen  tumid  and  un- 
comfortable, and  will  remain  entirely  without  rest  for  the 
remainder  of  the  night ;  or  if  he  drop  off  for  a  few  mintues  into 
unconsciousness,  it  seems  rather  to  aggravate  than  relieve  the 
feverish  restlessness,  and  to  cause  headache. 

The  most  serviceable  remedy  is  finely-powdered  animal  char- 
coal, in  doses  of  from  ten  to  twenty  grains,  and  of  the  aloes-and- 
myrrh  pill  just  enough  nightly  not  to  act  as  a  purgative.  The 
air  seems  to  be  absorbed,  and  the  peristaltic  motions  quickened, 
by  this  treatment.  Should  that  not  be  effectual,  you  can  employ 
strychnine  in  small  doses  in  the  pill. 

It  is  scarcely  needful  to  say  that  indigestible  articles  of  diet 
must  be  shunned,  if  the  patient  would  avoid  a  recurrence  of  the 
complaint;  and  it  stands  to  reason  that  cold  sponging  and 
bathing,  sea-water— and  in  short  all  hygienic  remedies  which 
improve  the  general  health — will  conveniently  accompany  the 
treatment. 

I  have  known  two  cases  of  habitual  looseness  of  bowels  cured 
by  marriage.  In  one  of  these  the  change  was  sudden  and  im- 
mediate :  a  gentleman  from  boyhood  to  the  age  of  thirty-five  had 
been  used  to  have  the  bowels  opened  at  least  five  times  a  day ;  a 
week  after  his  wedding  the  number  of  evacuations  was  reduced 
to  two,  and  before  the  year  was  out  to  one  daily.  I  presume  it 
is  requisite  for  the  marriage  to  be  a  happy  one — a  Xantippe 
would  not,  probably,  lead  to  the  same  soothing  result. 


LECTURE    XLVI, 

COSTIVENESS    AND    CONSTIPATION. 

Tlie  difference,  between  them — Costiveness  dependent  on  retained 
excernihle  matter — What  diseases  it  accomjyaiiies — Cause,  de- 
fective vitality — Effect  on  the  nervous  system  and  mind  of 
retained  excernihle  matter — Indications  of  treatment — Incon- 
veniences of  purgatives — What  sort  of  purgatives  are  to  he 
adopted — Dietary  —  "Water —  Watering  p)laces — Cautions  in 
use  of  them — Hydropathy —  Constipation —  Causes — Irritating 
food —  Unabsorhable  food  —  Remedies  —  Flatulence  in  colon 
distinguished  from  that  in  ilia — Remedies — Slight  eases  diffi- 
cult to  relieve. 

{Extra  Course,  St.  Mary's,  Summer  Session,  1857.) 

The  opposite  states  to  diarrhoea  are  "  costiveness"  and  "con- 
stipation." In  the  former  the  quantity  of  faeces  is  too  small: 
in  the  second,  the  expulsive  power  is  in  default. 

Costiveness  arises  from  deficient  excretion  into  the  alimen- 
tary canal.  What  proportion  of  the  matters  that  ought  to  be 
thus  got  rid  of  comes  from  the  liver  we  have  not  yet  the  means 
of  knowing,  but  the  main  point,  that  they  are  derived  from  por- 
tal blood,  we  are  justified  in  asserting ;  so  that  the  solution  of 
the  former  question  is  of  the  less  importance. 

That  a  great  deal  of  the  color  of  faeces  is  due  to  bile  is  fami- 
liar to  us  from  the  phenomena  attendant  on  obstructed  gall- 
ducts.  But  even  when  there  is  complete  occlusion  of  the  com- 
munication between  the  liver  and  intestines,  the  faeces  by  no 
means  consist  entirely  of  undigested  food ;  there  is  in  them  a 
great  proportion  of  yellowish-gray  granular  matter  which  appears 
also  in  the  healthy  state,  and  still  makes  up  the  bulk  of  the  solid 
excreta. 


COSTIVENESS  AND  CONSTIPATION.  561 

In  deficiency,  therefore,  of  the  excretive  powers  of  the  intes- 
tines generally  {vulgo  "  costiveness"  or  "biliousness"),  there  is 
a  different  substance  retained  than  is  the  case  when  local  lesion 
of  the  liver  or  gall-bladder  obstructs  the  passage  of  bile.  There 
is  a  partial  retention  of  the  whole  matters  destined  for  depura- 
tion from  these  quarters,  instead  of  a  complete  retention  of  one 
constituent. 

Hence  there  is  not,  as  happens  in  mechanical  retention  of  the 
bile,  the  well-known  stain  of  jaundice  communicated  to  the  blood 
and  skin,  nor  are  the  stools  clay-colored.  But  there  is  a  dingi- 
ness  and  darkness  of  complexion,  and  the  stools  are  scanty.  The. 
skin  gets  greasy  and  opaque,  the  countenance  sometimes  puffy 
and  bloated,  sometimes  thin  and  pale,  the  lower  eyelid  especially 
sallow  and  discolored.  The  sebaceous  follicles  on  the  alte  nasi 
are  stopped  up  with  black  matter. 

There  is  seldom  any  decided  emaciation,  nor  is  there  always 
even  loss  of  muscular  power;  but  still  there  is  great  sluggish- 
ness of  body  and  apathy  of  mind,  and  often  a  miserable  want 
of  decision  and  energy.  Digestion  is  accompanied  by  a  good 
deal  of  discomfort  and  flatulence,  but  rarely  by  actual  pain,  and 
the  distress  does  not  begin  till  several  hours  after  eating,  so  as 
to  be  with  difficulty  referred  to  any  particular  meal. 

In  the  least  complicated  cases  of  checked  intestinal  secretion 
the  stools  are  dark,  hard,  and  dry ;  but  their  appearance  may  be 
varied  by  several  circumstances.  Sometimes  there  is  an  aug- 
mented secretion  of  mucus,  and  then  they  are  intimately  mixed 
up  with  it,  forming  a  black,  slimy,  almost  gelatinous  mass. 
Sometimes,  from  the  appetite  not  suffering,  the  patients  will  eat 
largely,  and  then  there  appears  irregularly  from  time  to  time  a 
quantity  of  fetid,  semi-digested  food,  constituting  a  sort  of 
diarrhoea  accompanied  with  pain  and  colic.  And  this  diarrhoea 
will  often  be  the  occasion  of  your  patient's  first  coming  to  you, 
so  that  you  might  be  deceived  into  a  false  impression  of  the  case. 

The  congestion  of  the  portal  vessels  in  the  upper  part  of  the 
alimentary  canal  is  often  followed  by  the  same  state  in  the 
lower,  and  thus  piles  are  formed,  which  add  much  to  the  general 
distress. 


562  COSTIYENESS  AND  CONSTIPATION. 

Costiveness  is  a  common  accompaniment  of  anaemia,  chlorosis, 
debility  in  males  and  females, or  diseased  hearts — especially  where 
the^muscle  is  dilated  rather  than  hypertrophied,  of  contracted 
liver,  and  in  short,  of  anything  which  makes  the  abdominal 
circulation  sluggish.  Sometimes  it  is  found  in  cases  of  pulmo- 
nary tuberculosis,  but  hardly  ever  before  middle  age.  In  old 
age  it  may  be  considered  the  normal  state  of  the  abdominal 
viscera.  All  those  pulmonary  cases  in  which  I  have  seen  it  last 
long  enough  to  be  a  marked  feature  have  been  examples  of 
senile  phthisis.  It  is  often  the  first  and  most  characteristic 
phenomenon  of  that  change  of  system  which  takes  place  in 
females  after  the  cessation  of  the  catamenia.  The  stools  get 
gradually  more  and  more  scanty  as  the  uterine  secretion  also 
diminishes,  the  pulse  grows  feebler,  the  feet  and  hands  more 
liable  to  get  cold.  There  is  evidently  lessened  vitality  through- 
out the  whole  body. 

No  persons  more  frequently  suffer  from  costiveness  and  its 
attendant  "biliousness"  (as  the  general  appearance  of  the  skin 
is  named)  than  old  Indians.  Their  sedentary  routine  life  and 
high  feeding  are  partly  chargeable  with  their  liability.  But  in 
addition  to  this,  the  endemic  diseases  of  the  country  are  often  the 
exciting  cause.  I  have  traced  the  commencement  of  a  costive 
habit  of  body  several  times  distinctly  to  an  attack  of  dysenteric 
fever  brought  on  by  malaria.  So  that  the  Anglo-Indian  who 
suffers  in  this  way  must  not  be  always  accused  of  previous 
excess. 

One  end  of  this  state  of  things,  if  left  unchecked,  is  gradual 
progress  from  bad  to  worse.  The  decrease  of  destructive  as- 
similation loads  the  tissues  with  effete  matter,  useless  for  the 
purposes  of  life,  and  a  constant  source  of  general  discomfort. 
This  impedes  the  constructive  assimilation  of  food  as  well — 
growth  is  arrested,  the  blood  is  not  renewed,  and  hence  pro- 
gressive antemia,  weakness,  want  of  nervous  and  muscular 
power,  and  probably  in  the  end  the  degeneration  of  one  or  more 
of  the  viscera,  and  death  from  that  cause. 

A  very  striking  attendant  on  the  loss  of  destructive  assimi- 
lation, is  the  depression  of  spirits ;  melancholy  is  so  named  from 


-1 


COSTIVENESS  AND  CONSTIPATION.  563 

the  dark,  scanty  stools  which  were  observed  by  the  Greeks  to  be 
associated  with  it.  It  appears  to  me  to  be  a  universal  rule  in 
disease  that  the  general  discomfort  is  proportioned  to  the  arrest 
of  this  vital  process,  and  I  am  inclined  to  attribute  it  almost 
entirely  to  the  influence  on  the  nerves  of  general  sensation  of 
effete  matter  which  is  retained.  In  all  maladies,  both  acute  and 
chronic,  you  may  observe  the  truth  of  this  law.  Mark,  for  in- 
stance the  ushering  in  of  a  fever:  the  malaise  is  excessive; 
there  are  pains  in  the  back,  in  the  head  and  the  limbs,  or,  in 
milder  cases,  a  sense  of  what  the  patients  graphically  call  "all 
overishness;"  but  when  they  get  worse,  and  destruction  begins, 
the  effete  matter  passing  off  as  urea  and  increasing  the  specific 
gravity  of  the  urine, — then  no  aggravation  of  local  symptoms, 
however  much  it  may  alarm  their  physician,  and  make  his 
prognosis  graver,  prevents  the  general  feeling  of  relief.  Or 
watch  a  case  of  consumption ;  the  deposit  of  tubercle  may  be 
insignificant,  and  is  at  all  events  in  its  first  stage;  yet  the 
patient  is  despairing  of  recovery.  Why  ?  Because  the  skin  is 
sluggish,  the  bowels  costive,  the  urine  of  low  specific  gravity; 
because,  in  short,  there  is  evidence  of  the  retention  of  effete 
matter  in  the  system.  But  let  this  patient's  tubercles  soften, 
let  there  be  night  sweats,  copious  expectoration,  diarrhoea — 
everything  that  prophecies  ill — and  who  so  full  of  hope  as  the 
poor  blind  sufferer?  Morbid  states  where  destruction  is  in 
excess  are  the  most  fatal,  but  those  where  retention  preponder- 
ates are  invariably  the  most  distressing. 

Costiveness  must  be  regarded  as  a  disorder  of  the  whole  sys- 
tem,  and  not  of  the  intestinal  canal  alone.  The  only  effectual 
remedies  are  those  that  are  advised  under  that  conviction. 

The  objects  of  treatment  must  be :  first,  to  relieve  the  body 
of  the  immediate  presence  of  effete  matter;  and,  secondly,  to 
prevent  artificially  its  reaccumulation  till  such  time  as  a  com- 
plete renewal  of  the  tissues  has  taken  place.  Then  the  body 
ought  to  be  able  to  take  care  of  itself,  and  a  cure  may  be  said  to 
have  been  performed.  The  attention  to  local  disorders,  arising 
from  the  successful  study  of  morbid  anatomy,  has  too  much 
made  us  forget  this  main  object  of  all  medical  advice — the  re- 


564  COSTIVENESS  AND  CONSTIPATION. 

placement  of  morbid  tissue  by  healthy.  '•'■  Reneiv  my  age,"  was 
the  chief  earthly  blessing  prayed  for  by  the  inspired  prophet ; 
and  physiology  teaches  us  it  should  be  the  motto  of  the  rational 
physician;  for  if  he  omits  to  rebuild  the  healthy,  his  care  for  the 
destruction  of  the  unhealthy  is  all  thrown  away. 

Purgatives,  then,  may  very  fairly  begin  the  treatment ;  for 
the  immediate  relief  they  give  to  the  feelings  of  discomfort  is 
great.  But  let  not  that  relief  be  set  down  to  the  mere  "  clear- 
ing out  of  the  bowels;"  it  is  the  cleansing  of  the  blood  which  is 
the  real  object  of  the  remedy,  and  the  real  cause  of  the  relief. 
An  inspection  of  what  comes  away  shows  you  it  has  been  newly 
formed;  it  is  fresh  bile  and  other  natural  constituents  of  recent 
faeces;  not  of  those  which  have  rested  long  in  the  canal. 

Nothing  is  easier  than  thus  with  a  vigorous  blue-pill  and  black 
draught  to  drive  away,  as  with  a  charm,  the  patient's  discom- 
forts ;  and  he  is  ready  enough  to  cry  out  that  no  more  medicine 
is  wanted.  But  what  is  the  consequence  of  leaving  off  treat- 
ment ?  The  renewal  of  the  blood  and  tissues  not  having  had 
time  to  regain  its  original  activity — there  not  being  enough  new- 
made  blood  to  carry  on  vigorous  life — the  effete  materials  again 
collect,  and  the  disease  takes  a  fresh  starting-point.  Again 
and  again  the  coarse  expedient  is  called  for,  and  at  last  fails  to 
effect  its  object  of  giving  relief. 

To  avoid  this  evil  consequence  it  is  best  to  give  no  quickly- 
acting  complete  purgatives  which  directly  deplete  the  abdominal 
plethora  by  serous  exudation:  but  rather  such  as  cause  a  gra- 
dual increase  in  the  solid  matter  of  the  stools.  Aloes  and  rhu- 
barb are  the  best  of  these;  and  I  find  it  also  beneficial  to  com- 
bine with  them  resins  which  act  as  a  tonic  to  the  surface  of 
the  mucous  membrane,  and  prevent  the  exudation  of  serum  and 
mucus.  Four  grains  of  aloes-and-myrrh  pill  every  night  will 
in  a  week  produce  all  the  good  effect  of  strong  purgation;  and 
it  will  produce  the  good  permanently  instead  of  merely  for  a 
time. 

All  accessory  food  that  has  the  property  of  arresting  destruc- 
tion must  be  left  off.  Wine,  beer,  tea  and  coffee  must  on  this 
account  be  excluded  from  the  dietary;  and  milk,  cocoa,  whey, 
soda-water,  Seltzer-water,  &c.,  substituted  for  them. 


COSTIVENESS  AND  CONSTIPATION.  5G5 

Perhaps  it  is  on  account  of  their  temporary  arrest  of  destruc- 
tive assimilation,  that  general  tonics,  such  as  cinchona  and 
quinine,  rarely  agree  well  in  those  cases.  I  find  it  better  to 
give  pure  bitters,  such  as  oak-bark,  quassia,  and  gentian,  which 
seem  to  act  chiefly  on  the  mucous  membrane.  Their  use  is  to 
increase  the  appetite;  and  when  that  object  is  attained,  I 
leave  them  oS";  or,  if  it  is  attained  without  them,  I  do  not 
begin. 

Water  is  a  very  accessible  remedy,  and  certainly  a  very  ra- 
tional one,  when  the  destructive  assimilation  is  deficient.  The 
conclusive  experiments  of  Dr.  Bocker  and  of  Dr.  Falck,*  show 
the  increase  of  all  interstitial  metamorphosis  by  this  agent  to 
be  in  close  proportion  to  the  quantity  taken,  within  certain 
bounds;  and  all  who  have  heard  or  read  of  the  agreeable  sensa- 
tions experienced  by  patients  during  the  water  cure,  cannot 
doubt  its  power  of  removing  morbid  accumulations  of  effete 
matter  in  the  tissues.  In  this  lies  its  strength ;  for,  as  Dr. 
Bocker  observed,  "  the  demand  for  new  tissue,  as  expressed  in 
the  sensation  of  hunger,  keeps  pace  exactly  with  the  extent  of 
the  metamorphosis."  And  if  this  demand  is  rightly  supplied, 
the  result  must  be  a  complete  renewal  of  the  body. 

The  testimony  of  experience  to  the  use  of  water  as  a  remedial 
agent,  is  shown  in  the  patronage  bestowed  from  the  earliest 
times  upon  numerous  springs  whose  saline  constituents  are  even 
less  abundant  than  those  of  ordinary  drinking  water.  Pfeffers, 
historically  famous  for  freeing  Martin  Luther  of  his  deuion- 
haunted  hypochondriasis,  is  still  the  resort  of  the  invalid.  It  is 
situated  in  a  most  gloomy  hole :  and  the  copious  hot  stream  that 
boils  out  of  the  rock  is  almost  chemically  pure.  So  that  really 
the  pure  nymph  of  the  fountain,  innocent  of  salt,  should  have 
the  whole  credit.  The  same  may  be  said  of  the  well-known 
Gastein  and  Wildbad,  the  crowded  Baden,  imperial  Plombieres, 
of  the  French  Aix,  and  our  own  long-frequented  Buxton  ;  for 
practically  speaking,  the  influence  of  the  saline  particles  they 

*  See  "Digestion  and  its  Derangements,"  p.  217;  and  "  Zeitsclirift  der  K. 
K.  Gesellschaft  der  Aertze  zu  Wien,"  April,  1854;  and  Vierordt's  "  Archiv.,"  i, 
p.  150,  1853. 


56G  COSTIYENESS  AND  CONSTIPATION. 

contain  must  be  reckoned  for  nothing.  It  is  certainly  nothing 
as  compared  with  the  effects  of  moderate  doses  of  water  in  Dr. 
Becker's  experiments. 

As  physiologists  we  cannot  be  surprised  at  the  benefit  derived 
from  the  simple  expedient  of  drinking  water  beyond  the  demands 
of  thirst,  in  all  diseases  of  arrested  metamorphosis.  Taken 
several  times  a  day  between  meals  it  is  a  most  efficient  remedy. 
Warm  hip-baths  are  also  of  great  use,  and  can  be  borne  even 
from  the  first  by  those  reduced  to  extreme  ansemia  and  lifeless- 
ness.  Afterwards  the  cold  sponge-bath,  preceded  and  followed 
by  friction  to  the  skin,  is  a  most  active  promoter  of  life  in  the  skin 
and  capillaries.  The  raising  the  specific  gravity  of  the  water  by 
the  addition  of  salt  prevents  the  chill  which  fresh  water  is  apt 
to  impart.  So  that  even  persons  with  cold  hands  and  feet,  and 
great  sluggishness  of  circulation,  can  bear  to  be  sponged  with 
brine. 

Alkalies  and  neutral  salts  have  the  same  action  on  the  moult- 
ing of  effete  tissues  that  water  has.  Hence  the  repute  of  many 
really  strong  mineral  wells.  But  care  is  needed  lest  the  same 
result  should  follow  their  use  which  is  threatened  by  the  un- 
guarded use  of  purgatives.  In  cases  where  there  is  arrest  of 
metamorphosis  without  organic  change  in  any  of  the  viscera,  I 
find  that  the  weaker  the  spring  the  better  for  the  patient. 

While  pulling  down  an  old  house,  remember  to  be  building 
up  the  new.  Let  full  supplies  of  albuminous  material  be  con- 
tinuously kept  up  in  such  form  as  the  absorbents  love.  Let 
milk,  mutton,  and  bread  be  the  staple  diet,  with  the  smallest 
quantity  of  anything  else  that  human  weakness  will  submit  to. 
If  your  patient  be  one  of  strong  mind,  the  best  and  bravest  thing 
is  for  him  to  carry  out  your  advice  himself.  He  will  then  have 
gained  a  victory,  not  only  over  the  flesh,  but  over  the  spirit. 
But  if  he  is  no  Stoic,  and  cannot  attain  to  the  dignity  of  being 
his  own  gaoler,  do  not  be  afraid  of  sending  him  to  a  hydro- 
pathic hotel.  You  Avill  generally  find  the  owners  of  these 
houses  willing  to  carry  out  your  directions,  and  the  situations 
of  most  of  them  are  well  chosen  for  the  advantages  of  air  and 
amusement. 


COSTIVENESS  AND  CONSTIPATION.  567 

I  know  that  medical  men  arc  afraid  that  in  sending  patients 
to  water-cure  establishments  they  may  be  aiding  and  abetting 
the  pretensions  which  ignorant  proprietors  have  put  forth,  of 
their  treatment  being  a  panacea  for  all  ailments.  Now,  in  my 
opinion  scientific  hydropathy,  the  renewal  of  the  body  by  water 
and  food,  the  increase  of  growth  secondary  to  the  increase  of 
moulting,  is  no  quackery.  It  is  not  an  underhand  mode  of 
doing  nothing,  but  a  bond  fide  use  of  a  powerful  agent.  And 
therefore  a  contrary  effect  than  what  has  been  feared  would 
follow ;  for  the  very  fact  of  regular  practitioners  adopting  the 
treatment  as  remedial,  will  show  that  science  ranks  it  as  a  phy- 
sical power;  that,  consequently,  it  will  do  as  much  harm  in 
some  cases  as  it  does  good  in  others  ;  in  fact,  that,  like  all 
medical  treatment,  it  will  kill  as  well  as  cure,  and  needs  as 
much  prudence  in  its  administration,  and  as  much  science  to 
prescribe  it  rightly  as  the  most  powerful  agent  in  the  pharma- 
copoeia. 

Constipation  is  often  added  to  costiveness,  but  is  not  neces- 
sarily connected  with  it.  The  faeces  collect  in  some  part  of  the 
abdominal  canal,  and  give  proof  of  that  collection  by  being  oc- 
casionally passed  in  considerable  quantities  at  a  time.  In  the 
stools  there  are  portions  drier  than  the  general  mass — scybala 
of  various  sizes,  dark  brown  or  black,  and  with  less  smell  than 
ordinary  faeces. 

The  most  typical  cause  of  constipation  is  mechanical  obstruc- 
tion, the  nature  of  which  under  various  forms  has  been  fully  ex- 
plained to  you  in  the  ordinary  courses  of  medical  and  surgical 
lectures. 

Atony  of  the  colon  presents  a  much  more  frequent  and  more 
curable  cause.  And  not  rarely  a  mucous  flux  of  the  stomach 
or  intestines  will  originate  it  by  folding  up  the  faeces  in  a  slimy 
coat,  and  preventing  their  being  moved  on  by  the  muscular  con- 
tractions of  the  gut.  Atony  of  the  colon  arises  primarily  in 
those  who  lead  a  sedentary  life,  and  have  that  pale  look  which 
characterizes  weak  muscular  fiber.  It  is  more  frequent  in  the 
old  than  the  young  ;  indeed,  a  diminished  propulsive  force  in  the 
large  intestines  may  be  considered  as  a  normal  consequence  of 
advanced  age. 


568  COSTIVENESS  AND  CONSTIPATION. 

Keglect  of  the  natural  call  to  evacuate  the  bowels  also  pro- 
duces this  sort  of  torpidity  by  too  long-continued  dilatation. 
Hysteria  and  nervousness  often  spasmodically  contract  the  rec- 
tum, so  that  the  faeces  are  kept  back,  and  the  same  state  of 
things  arises  as  from  neglected  evacuation. 

When  the  colon  tends  to  be  atonic,  this  diathesis  is  much 
aggravated,  and  sometimes  first  made  evident,  by  peculiar  kinds 
of  diet.  It  is  a  mistake  to  suppose  that  indigestible  articles  of 
food  "irritate,"  or  pass  on  quicker  than  more  soluble  substances. 
The  reverse  is  true  ;  and,  as  a  general  rule,  the  regular  trans- 
mission of  the  mass  is  in  proportion  to  the  completeness  of  its 
digestion.  No  sort  of  food  is  so  apt  to  be  followed  by  consti- 
pation in  atonic  persons  as  that  which  contains  a  large  amount 
of  matter  incapable  of  being  acted  upon  by  the  digestive  juices, 
such  as  the  husks  and  stones  of  fruit,  half-cooked  vegetables, 
in  which,  besides  cellulose,  there  is  the  equally  impractica- 
ble body,  unbroken  starch.  All  substances  capable  of  being 
squeezed  into  a  tough  mass,  such  as  puff  pastry  and  new  bread, 
come  under  the  same  class  of  insolubles  ;  and  gum  and  gelatin 
are  liable  to  the  same  imputation  according  to  some  observers. 

The  most  successful  practice  in  simple  constipation  is  the  free 
use  of  cold  water  enemata,  and  a  long-continued  course  of  small 
doses  of  strychnine.  When  there  are  no  piles,  the  latter  medi- 
cine may  be  advantageously  combined  with  aloes.  This  treat- 
ment does  not  forbid  the  administration  of  tonics,  or  whatever 
else  may  be  needful  to  relieve  the  disease  in  which  constipation 
occurs ;  which  disease  of  course  requires  to  be  removed  before 
the  local  symptom  will  be  free  from  risk  of  relapse.  It  is  scarcely 
necessary  to  say, that  no  treatment  will  avail  if  the  bad  habits 
which  have  induced  the  constipation  are  persisted  in. 

Constipation  may  often  be  much  alleviated  by  oleaginous  arti- 
cles of  diet,  such  as  butter,  bacon,  &c.,  being  taken  with  the  usual 
food.  This  is  especially  the  case  with  old  people,  who  are  apt 
to  be  too  abstemious  in  this  respect. 

If  the  constipation  arise  from  impediments  to  the  movements 
of  the  bowels  upon  one  another,  such  as  adhesions,  scars  of  old 
ulcers,  compression  of  the  area  of  the  gut,  tumors,  retrover- 
sion of  the  uterus,  and   the    like,  a  more  soothing  treatment 


COSTIVENESS  AND  CONSTIPATION.  569 

should  be  adopted.  Then  the  enemata  shouhl  be  warmed,  and 
have  an  ounce  of  olive  oil  added  to  them.  If  there  be  local 
pain,  dissolve  a  little  opium  in  the  oil,  and  put  some  leeches 
on  the  spot  corresponding  to  the  seat  of  pain.  Hot  fomenta- 
tions and  poultices  containing  fresh  laurel  leaves  also  give  great 
relief. 

The  depending  position  of  the  caecum  makes  it  the  commonest 
seat  of  fffical  collections ;  and  if  you  find  it  diflBcult  to  fix  on 
any  other  spot,  it  is  wise  to  take  it  for  granted  that  this  is  the 
failing  one,  and  direct  your  local  application  accordingly.  And 
do  not  be  satisfied  with  the  one  or  two  very  copious  stools  which 
will  follow  your  efforts ;  the  treatment  must  be  persevered  in 
until  the  bowel  has  recovered  its  tone,  or  there  will  be  a  great 
risk  of  relapse. 

Remember  what  I  said  about  costiveness  being  a  normal  condi- 
tion of  advancing  years,  and  vary  your  treatment  according  to 
the  age  of  the  patient.  Do  not  demand  from  sexagenarian  bowels 
the  same  activity  that  you  expect  from  two  and  twenty.  Daily 
evacuation,  which  should  be  the  rule  in  youth,  is  an  excess  in  an 
old  man,  and  still  more  in  an  old  woman.  Thrice  a  week  is  often 
enough  for  even  robust  persons. 

Flatulence  in  the  Colon  may  be  distinguished  from  that  in 
the  small  intestines  by  the  percussion,  by  the  absence  of  bor- 
borygmi,  and  by  its  frequently  passing  freely  out  per  anum.  It 
is  a  very  usual  accompaniment  of  constipation,  and  in  that  case 
has  the  same  pathology,  being  to  the  air  what  the  other  is  to  the 
solid  faeces.  If  the  flatulence  is  a  very  marked  symptom,  a  car- 
minative, such  as  extract  of  rue,  or  a  few  drops  of  ether,  may  be 
added  to  the  enema. 

When  the  abdomen  is  not  more  dilated  than  natural  by  flatu- 
lence, eff'orts  should  always  be  made  to  retain  the  wind  inside 
the  bowels.  For  not  uncommonly  the  parting  with  it  induces  a 
condition  of  constipation,  the  wind  really  acting  as  an  expander 
and  stimulant  to  the  colonic  muscular  fibers,  which  when  deprived 
of  it  fall  into  atony.  It  will  roll  about  uncomfortably  for  a  time, 
but  if  retained  it  either  becomes  absorbed  or  mixed  with  the 
faeces,  and  so  induces  a  normal  evacuation.  The  proof  of  this  is 
that  it  is  not  afterwards  passed. 


LECTURE    XLVIL 

DIETETICS. 

Thesis  of  Dietetics  based  on  the  principle  of  sparing  the  weakest 
part — I.  Stomach — //.  Intesti7ies — ///.  Increase  of  ab- 
sorption— IV.  Delay  of  absorption — V.  Gradual  return 
to  nonnal  diet. 

{Extra  Course^  St.  Mary's,  Summer  Session,  1857.) 

As  a  contribution  towards  clearing  away  the  mists  of  our 
clinical  dietetics,  I  purpose  to  set  before  you  to-day  certain 
theses  which  are  my  guides  in  this  matter,  and  perhaps  there- 
fore may  help  you  too. 

The  leading  idea  of  the  first-placed  and  most  important  rules 
is  simply  that  of  sparing  weak  members — working  those  that 
can  work,  and  resting  those  that  cannot. 


I. 

When  the  stomach  fails,  leave  the  digestion  as  much  as  possible 
to  the  intestines. 

This  applies  to  cases  of  weight  and  pain  after  eating,  heart- 
burn, acidity,  hsematemesis,  vomiting  of  unaltered  food,  and 
fermentation.  Should  the  conjunction  of  symptoms  enable  us 
more  definitely  to  diagnose  gastric  ulcer,  mucous  flux,  cancer, 
or  any  other  more  definite  anatomical  change,  the  application  is 
all  the  more  imperative. 

Spare  the  stomach  both  its  mechanical  and  its  chemical  toil. 

The  first  is  the  hardest,  and  therefore  the  most  necessary  to 
be  avoided.  A  meal — that  is,  the  laying  in  of  victuals  to  avoid 
future   rather   that   present   hunger — is    a  labor,  even   to  the 


DIETETICS.  571 

healthy ;  so  do  not  impose  it  on  a  sick  stomach.  In  very  bad 
cases,  do  not  divide  the  daily  allowance  into  meals*  at  all,  but 
assign  such  quantity  as  appears  enough  for  the  twenty-four 
hours,  and  let  the  taking  of  it  be  spread  over  the  whole  time, 
as  equally  and  with  as  short  intervals  as  possible.  In  milder 
cases  it  will  be  sufficient  to  ^^ spoil"  the  meals — that  is,  to  take 
food  between  the  usual  times,  so  as  to  leave  neither  the  neces- 
sity nor  the  inclination  for  eating  at  once  as  much  as  other 
people.  One  would  be  sorry  to  recommend  to  the  healthy  an 
over-care  for  their  diet,  but  to  invalids  subject  to  gastric  derange- 
ment, you  cannot  do  better  than  advise  an  imitation  of  a  famous 
centenarian  witness,  examined  by  the  scientific  judge,  who  said 
he  attained  his  great  age  by  always  "eating  before  he  was 
hungry,  and  drinking  before  he  was  dry." 

But  take  care  that  your  patients  do  not  spoil  their  dinner  and 
eat  it  too  :  that  last  error  Avould  be  worse  than  the  first.  Make 
it  a  rule  that  the  slightest  sense  of  repletion  is  to  be  a  warning 
to  desist. 

Another  valuable  expedient  for  sparing  the  organ,  in  cases  of 
slight  indisposition,  is  dilution  of  the  meal.  Copious  watery 
drinks  carry  the  food  on  quicker  through  the  p^^lorus,  and  give 
great  relief  to  over- sensitive,  irritable  stomachs.  But  at  the 
same  time  it  must  be  remembered  that  thus  the  time  for  the 
action  of  the  gastric  juice  is  shortened,  and  its  chemical  strength 
lessened,  so  that  more  is  given  for  the  intestines  to  do.  It  is 
better,  therefore,  to  let  this  dilution  be  practiced  as  long  after 
the  meal  as  the  case  admits  of.  It  should  be  avoided  also  as  a 
general  rule  where  an  obstructed  circulation  impedes  absorption 
of  the  water  by  the  portal  veins.  Patients  with  dilated  heart, 
for  example,  and  some  cases  of  antemia  and  of  diseased  liver 
sufi'er  much  inconvenience  from  a  sloppy  diet.  Obese  persons 
also  should  avoid  dilution ;  it  washes  away  the  albumen  which 
they  do  want,  and  allows  the  absorption  of  fat,  which  they  are 
better  without. 

*  A  Meal  (as  in  Saxon  "  male,"  in  German  "  mahl,"  and  "mal"  implies 
apportionment  of  food,  lime,  or  anything  else.  So  Bacon — "  the  yearly  rent  is 
still  paid  into  the  hanaper  in  parcel  meal " — that  is,  "  in  lots." 


572  DIETETICS. 

The  chemical  toil  of  the  stomach  may  be  spared  by  giving  it 
less  to  digest,  and  more  to  digest  with.  Take  care  that  the 
weak  but  well-meaning  organ  is  not  driven  to  despair  by  solid 
lumps  of  albuminous  food.  The  best  form  of  nitrogenous  ali- 
ment in  these  cases  is  whey,  or  milk  prevented  from  coagulating 
by  a  copious  admixture  of  lime-water.  This  fluid  meat  will 
pass  through  the  stomach  unaltered,  the  gastric  juice  will  trickle 
through  the  pylorus  at  its  leisure  after  it,  and  with  the  intestinal 
juice  will  digest  the  casein  in  the  intestines.  Next  in  easy 
solubility  comes  soup,  made  fresh,  weak,  and  at  a  low  tempera- 
ture ;  fresh — that  it  may  not  decompose;  weak — that  it  may 
be  easily  absorbed  ;  at  a  low  temperature — that  it  may  not  be 
filled  with  innutritious  gelatin,  or  with  the  hard-boiled  albumen. 
Meat  is  suitable  in  proportion  as  it  is  soft,  easily  disintegrated, 
quickly  cooked,  and  free  from  fat,  which  might  oppose  the 
soaking  in  of  the  gastric  juice.  The  well-known  list  of  Dr. 
Beaumont  sets  in  the  order  of  these  qualities  a  great  number  of 
articles  of  diet.  But  I  thing  it  more  useful  for  you  to  have  the 
principles  of  selection  than  a  mere  experimental  enumeration  of 
the  articles  themselves. 

To  mix  starchy  food  with  the  albuminous  in  cases  of  weak 
digestion  is  an  irrational  practice.  It  soaks  up  the  little  that 
there  is  of  the  valuable  gastric  juice,  and  then  makes  no  use  of 
it ;  for  starch  is  quite  unaltered  by  the  peptic  solvent.  This  is 
very  bad  economy  indeed.  Moreover,  if  taken  in  quantity  suf- 
ficient to  assist  much  as  a  nutriment,  it  is  too  bulky,  and  being 
converted  into  sugar  by  the  saliva,  turns  acid  in  a  mass,  and 
puts  a  stop  to  further  digestion.  This  is  particularly  the  case 
if  it  is  in  solid  coherent  lumps,  such  as  potatoes,  soft  bread, 
pastry  and  the  like. 

Starchy  food,  unmixed  with  albuminous,  is  a  different  thing 
altogether.  There  are  certainly  some  cases  of  gastric  disorder, 
which  are  much  benefited  by  a  temporary  adoption  of  such  a 
diet.  It  is  the  best  during  acute  catarrhal  bilious  attacks,  at 
the  commencement  of  treatment  in  even  chronic  gastric  cases, 
and  whenever  a  dusky  complexion,  hypochondriasis,  or  general 
distress,  show  that  arrested  moulting  has  caused  a  collection  in 


DIETETICS.  573 

the  body  of  effete  tissues.  The  putting  the  patient  on  simple 
starchy  diet  does  good  in  fact  as  a  temporary  and  partial 
starvation  in  rheumatic  fever.  Hence  you  will  see  me  occa- 
sionally begin  the  treatment  of  such  cases  by  our  "simple  diet," 
and  still  often er  in  private  practice,  Avhere  starvation  for  a  time 
is  more  generally  wanted  than  in  hospitals,  I  allow  patients  for 
a  day  or  two  nothing  but  arrowroot,  panada,  tapioca,  gruel, 
&c.  This  gives  the  congested  portal  system  time  to  disembar- 
rass itself  so  as  to  leave  a  clear  space  for  the  taking  up  fresh 
supplies. 

As  you  return  from  a  purely  starchy,  or  purely  animal  diet,- 
to  that  mixture  of  the  two  which  is  normal  and  necessary  to  the 
healthy  condition,  or  if  you  consider  that  the  case  is  not  bad 
enough  to  oblige  you  to  adopt  either  one  or  the  other  absolutely, 
you  may  be  of  use  by  so  arranging  that  the  two  sorts  of  aliment 
shall  not  be  together  at  once  in  the  stomach.  For  example,  let 
the  morning  and  the  evening  diet  be  vegetable,  and  then  let 
several  hours  pass  before,  and  again  several  hours  after,  a  mid- 
day meal  of  purely  animal  food. 

Spare  thus  the  stomach  by  giving  it  less  to  digest.  You  have 
no  need  to  be  afraid  of  starving  your  patient  by  diminishing  the 
quantity  eaten.  A  little  food  digested  goes  much  further  than 
double  the  amount  only  swallowed.  For  example,  you  saw  last 
time  we  Avent  round  the  hospital  a  girl  in  the  corner  of  Victoria 
Ward,  who  had  gained  four  pounds  in  weight  during  six  days  on 
the  sole  allowance  of  three  pints  of  milk  and  less  than  twelve 
ounces  of  bread  per  diem.  A  man  in  Albert  Ward  has  also 
visibly  gained  flesh  in  the  same  time,  though  he  has  only  a  pint 
of  beef-tea  besides  what  I  mentioned  as  the  girl's  allowance. 
He  is  too  weak  to  stand  in  the  scales,  but  the  increase  is  appa- 
rent to  the  eye.  Both  these  patients  had,  till  their  admission 
to  St.  Mary's  been  trying  to  strengthen  themselves  by  meat 
and  whatever  they  could  get,  but  having  gastric  ulcers  did  not 
digest  it,  and  were  rapidly  emaciating. 

Spare    it  also  by  giving   it  more  to   digest  tvitli.     I  mean  by 
supplying  an  artificial   gastric  juice.     This  is  a  mode  of  treat- 
ment so  interesting,  from  our  being  enabled  of  late  years  to  use 
37 


574  DIETETICS. 

it  -with  novel  facility,  that  I  shall  make  it  the  subject  of  a  sepa- 
rate lecture,  and  thus  give  further  details  of  its  working  than  I 
have  time  for  to-daj. 

II. 

When  the  small  intestines  fail,  spare  them. 

Of  acute  diseases,  this  applies  particularly  to  continued  low 
fever  (during  both  its  height  and  its  sequelae),  to  enteritis,  diar- 
rhoea and  cholera  ;  of  chronic  diseases,  to  ulceration,  tubercular 
deposits,  either  in  the  peritoneum.  Payer's  glands,  or  mesen- 
tery ;  and,  secondarily,  to  disease  of  the  liver. 

What  are  the  functions  of  the  small  intestines  in  relation  to 
different  forms  of  aliment  ?  and  what  colleagues  have  they  that 
can  be  trusted  to  take  their  duties  during  a  temporary  holiday  ? 
The  small  intestines  absorb  all  matters  soluble  in  water  and 
capable  of  endosmosis,  and  have  in  that  work  all  the  mucous 
membrane  of  the  alimentary  canal  to  assist  them.  They  con- 
vert starch  into  sugar  before  absorbing  it,  in  conjunction  with 
the  saliva  and  pancreatic  juice.  They  dissolve  albumen,  and 
convert  it  into  peptone,  in  conjunction  with  the  stomach.  But 
in  the  digestion  of  fat  they  have  none  to  help  them. 

All  ordinary  fats  and  oils,  then,  must  be  excluded  from  the 
dietary  of  patients  affected  with  the  last-mentioned  diseases. 
Even  cod-liver  oil,  so  peculiarly  wanted  in  phthisical  cases,  and 
so  easily  digestible,  will  often  become  rancid  in  ulcerated  bowels, 
and  aggravate  the  diarrhoea.  If  it  does  aggravate  the  diar- 
rhoea, depend  upon  it  more  harm  than  good  is  done  by  the 
remedy ;  leave  it  off  forthwith ;  the  case  is  an  unsuitable  one 
for  it  at  that  stage  of  the  disease.  And  if  cod-liver  oil  disagrees, 
si  fortiori  do  other  less  digestible  fats.  I  have  known  the  mere 
skimming  the  fat  from  broth  make  all  the  difference  whether  it 
were  digested  or  not,  and  the  leaving  off  such  a  simple  article  as 
butter  render  a  previously  ineffectual  treatment  immediately 
successful.  Starch  will  agree  only  on  the  conditions  that  it  is 
taken  in  small  quantities,  and  that  the  saliva  is  in  a  state  to  do 
alone  what  generally  it  has  the  small  intestines  to  help  it  in 


DIETETICS.  575 

doing.  If  the  secretions  of  the  mouth  are  deficient,  it  will  not 
agree.  Hence,  in  low  fever,  where  the  fauces  and  tongue  are 
dry,  you  will  never  see  me  order  arrowroot,  bread,  panada,  gruel, 
potatoes,  or  any  other  amylaceous  food.  When  they  are  eaten, 
they  will  be  found  unaltered  in  the  fteces,  and  not  rarely  cause 
considerable  aggravation  of  the  symptoms.  I  have  particularly 
observed  this  in  convalescent  patients  after  fever.  You  are  often 
surprised  by  an  unexpected  relapse ;  examine  the  stools,  and 
there  you  see  lumps  of  potatoes,  bits  of  pastry,  or  a  mass  of 
starch  granules.  The  foolish  friends  have  been  disobeying 
orders  and  giving  these  articles,  which  cannot  act  as  a  nutri- 
ment, and  do  act  as  a  poison. 

On  the  other  hand,  a  phthisical  patient,  with  a  clean  moist 
mouth,  will  generally  digest  such  things  well,  in  spite  of  his 
ulcerated  bowels,  provided  they  are  well  chewed  and  not  lumpy. 

Starchy  food  is  exceedingly  useful  as  a  placebo  to  persons 
whom  you  wish  to  keep  on  low  diet,  such  as  rheumatic-fever 
patients,  for  example. 

Albuminous  food  will  agree,  provided  the  stomach  is  doing  its 
duty.  But  you  must  not  forget  that  it  has  lost  a  potent  col- 
league, and  be  careful  to  prepare  the  food  so  as  to  require  only 
a  short  time  in  digestion.  Milk  must  not  be  passed  on  to  the 
small  intestines  by  being  guarded  with  alkalies,  but  had  better  be 
soured  and  made  into  whey.  Some  of  the  curd,  broken  up  quite 
small,  may  be  taken  with  it.  Frequent  dilution  with  watery 
drinks,  and  the  use  of  artificial  pepsine,  are  of  eminent  use  in 
these  cases,  so  as  to  ensure  the  absorption  of  the  food  as  quickly, 
and  as  high  up  in  the  intestinal  canal  as  possible. 

The  succeeding  rules  relate  to  the  proper  management  of 
absorption. 


III. 

Where  you  wish  to  hasten  absorption,  dilute  with  water. 
This  is  so  obvious  a  .consequence  of  those  laws  of  osmosis 
which  almost  every  course  of  lectures — anatomical,  botanical, 


576  DIETETICS. 

physiological,  medical — has  occasion  to  recite,  that  I  will  spare 
you  the  repetition. 

The  rule  finds  its  chief  application  in  acute  febrile  diseases, 
but  it  must  not  be  passed  over  in  ulceration  of  the  alimentary 
canal  and  other  local  ailments,  where  protraction  of  the  process 
is  painful,  or  in  emaciation  and  convalescence,  where  we  would 
not  wish  to  waste  time,  but  to  give  a  person  all  the  nutriment 
possible  in  the  day. 

IV. 

When  you  wish  to  delay  absorption,  dilute  with  solids. 
For  solids  to  act  as  diluents  they  must  of  course  be  incapable 
of  absorption  ;  and  the  substance  I  principally  refer  to  is  cellu- 
lose in  its  various  forms  of  chaff,  bran,  husks,  skins,  seeds  of 
fruit,  and  fresh  green  vegetables.  Cellulose,  being  incapable  of 
chemical  changes  there,  passes  unaltered  through  the  alimentary 
canal,  carrying  with  it  first  the  chyme  prepared  for  absorption, 
and  then  adding  its  bulk  to  the  faeces  excreted.  Thus  the  ab- 
sorption is  spread  over  a  longer  time  and  a  larger  surface  of 
mucous  membrane,  the  whole  of  which  is  brought  equally  into 
work.  A  collateral  advantage  is  that  the  peristaltic  wave  acts 
with  more  regularity  when  it  has  a  solid  to  propel,  than  when 
the  contents  of  the  tube  are  fluid  only.  The  rule  is  useful,  not 
so  much  at  the  sick  bed  as  for  the  prevention  of  sickness.  Many 
persons  are  made  ill  by  their  diet  being  more  immediately  diges- 
tible than  they  have  been  used  to.  Scotch  laborers  on  exchang- 
ing oatmeal  for  wheat-flour,  Finn  recruits  on  getting  bread  at 
head-quarters  without  birch-bark  in  it,  country  persons  on  com- 
ing to  London  or  Paris,  often  suffer  from  this  cause.  The  mode 
of  prevention  is  obvious  and  cheap  ;  cabbages,  brown-bread,  and 
charcoal  offering  types  of  remedies  readily  altered  according  to 
taste. 

In  the  administration  of  medicines,  something  may  be  learned 
from  the  same  expedient.  Quinine  occasionally  will  not  agree 
where  powdered  bark  or  decoction  of  bark  will  yet  succeed  very 
well ;  and  the  same  may  be  said  of  the  soluble  and  insoluble 


DIETETICS.  577 

salts  of  iron,  of  morphia  and  opium,  and  similar  articles  identi- 
cal in  all  but  insolubility,  I  believe  the  secret  is  that  a  slower 
and  more  graduated  absorption  is  gained. 

I  have  elsewhere*  stated  reasons  for  suspecting  that  gum 
and  gelatin  may  be  classed  among  unabsorbable  diluents  of  the 
food,  and  are  not  really  nutritious ;  but  the  argument  is  hardly 
suited  to  a  practical  lecture. 


When  the  diet  has  been  diminished,  return  gradually  to  the 
normal  in  quantity  and  quality. 

I  suppose  mere  instinct  teaches  this,  for  all  acknowledge  the 
justice  of  it  as  a  sort  of  truism,  and  agree  that  a  convalescent 
diet  should  be  "light"  at  first,  and  afterwards  more  "substan- 
tial." Perhaps  in  respect  of  quantity  error  is  rare;  but  the 
spirit  of  the  rule  in  regard  to  quality  is  often  lost  by  misinter- 
preting the  words  "light"  and  "substantial."  Scientific  men 
must  not  think  vaguely,  and  you  must  have  clearer  ideas  than 
the  old  nurses,  who  so  often  hurt  your  patients  by  misapplying 
these  expressions.  I  shall  not,  therefore,  think  I  am  wasting 
time  by  explaining  what  the  rule  really  means. 

I  formerlyt  divided  foods  into  such  as  are  capable  of  direct 
absorption  without  change,  and  such  as  require  a  previous  change 
by  the  digestive  juices  ;  and  the  same  division  has  also  been 
adopted  by  M.  Bernard.  By  subdividing  the  latter  class  into 
such  as  require  only  direct  chemical  change,  and  such  as  require 
disaggregation  as  well,  we  get  three  groups  of  aliments;  the 
first  the  "lightest"  or  most  digestible;  the  last  the  most  "sub- 
stantial ;"  the  second  intermediate.  M.  Bernard  observes  that 
the  first  group  necessitates  but  one  physiological  act ;  the 
second,  two  acts  ;  and  the  last,  three  ;J  and,  consequently,  in 

*  "  Digestion  and  its  Derangements,"  book  i,  p.  260. 

f  In  "Digestion  and  its  Derangements,"  boolv,  i,  p.  195. 

%  "Memoire  sur  la  Question  suivante  mise  au  Concours,  par  le  Society  de 
Medecine  de  Lyon,  pour  I'annee  1856,  &c.,  &c.."'  obtenue  par  M.  le  Dr.  Bernard, 
fils.     Lyon,  1857. 


578  DIETETICS. 

that  order  demand  a  proportionate  amount  of  labor  from  the 
system. 

Under  the  first  head  come  water,  essential  oils,  tea,  coffee, 
alcohol,  ethers,  salts,  sugar,  whej,  gravy  (containing  osmazome). 
Asses'  milk,  with  its  small  quantity  of  butter  and  casein,  and  its 
large  allowance  of  sugar,  forms  a  transition,  through  cow's  milk, 
to  the  second  class.  In  the  second  class  may  be  ranked  con- 
somme soup,  lightly  cooked  eggs,  well-boiled  liquid  starch.  In 
the  third  class,  tripe,  oysters,  sweetbread,  and  boiled  chicken 
come  nearest  to  the  second,  while  the  power  of  digesting  hard 
meats  (such  as  beef),  or  soKd  lumps  of  starch  (such  as  potatoes), 
shows  that  the  normal  strength  of  digestion  has  been  regained. 
This  is  something  definite,  and  with  this  idea  you  will  find  no 
difiiculty  in  making  a  graduated  scale  up  which  a  patient  may 
safely  mount  in  his  progress  through  convalescence. 

Before  the  full  powers  of  digestion  are  regained,  care  should 
be  taken  that  all  albuminous  food  be  not  over-cooked.  Too 
great  heat  renders  albumen  absolutely  insoluble.  For  this 
reason  baking  should  be  avoided  as  much  as  possible,  and  where 
it  is  unavoidable,  let  there  be  as  much  fluid  as  can  be  in  the  pie, 
or  whatever  else  is  submitted  to  this  form  of  cookery,  so  as  to 
assimilate  the  results  as  nearly  as  possible  to  stewing. 


LECTURE    XLVIIL 

CORPULENCE. 

Obesity  to  he  distinguished  from  fatty  degeneration — Origin  of 
adipose  tissue  from  food  either  containing  fat,  or  elements 
capable  of  conversion  into  it,  in  excess  over  the  respiratory, 
consumption — Presumed  possibility  of  relief  by  dietetic  treat- 
ment—  Tendency  to  obesity  congenital  and  hereditary — Deduc- 
tions from  thirty-eight  tabulated  cases  as  to  the  peculiarities 
of  obese  persons,  arid  the  exciting  causes  of  their  condition — 
Obesity  a  comparative  hypertrophy  arising  out  of  a  compara- 
tive vital  deficiency — Principles  of  rational  treatment  thence 
deduced — Difficulties  in  enforcing  their  adoption — Specimeyi 
of  detailed  scheine  of  dietary — Limits  to  attempts  at  reduc- 
tion—  The  action  of  medicines,  such  as  liquor  potassae,  vinegar, 
iodine,  and  diuretics,  discussed — Belts  and  baths — Prognosis 
of  obesity. 

{St.  Marys,  December  1,  1862.) 

As  Gulstonian  lecturer  I  delivered  at  the  College  of  Physicians 
in  1850  a  course  of  lectures  on  Corpulence,  and  published  them 
in  a  little  duodecimo  afterwards.  As  more  than  a  dozen  years 
have  passed  by,  and  the  volume  has  been  long  out  of  print,  I 
may  be  allowed  to  dish  up  some  old  matter,  and  to  give  you  an 
analysis  of  the  more  practical  parts  of  what  I  then  said  at  fuller 
length  before  a  more  stately  audience. 

In  the  first  place,  I  carefully  distinguished  obesity,  or  the  in- 
convenient presence  of  a  large  quantity  of  normal  fat,. from  fatty 
degeneration  of  existing  tissues.  I  traced  the  origin  of  the  true 
adipose  tissue,  showing  by  well-established  physiological  obser- 
vations that  it  is  derived  entirely  from  the  food  eaten,  in  a  great^ 


580  CORPULENCE. 

measure  directly,  as  fat  previously  ready  made,  and  partly  from 
articles  readily  converted  chemically  into  fat.  And  I  laid  down 
the  law  that  for  the  formation  of  fat  the  preliminary  need  is 
that  the  materials  be  digested  in  greater  quantity  than  is  suffi- 
cient to  supply  carbon  in  equal  amount  to  that  consumed  in  the 
respiration. 

Thus  I  showed  the  probability  that  by  modification  of  diet  we 
may  be  enabled  to  govern  effectually  at  will  the  formation  of  fat 
in  the  human  body. 

The  next  point  I  aimed  at  making  was  that  the  excess  of  fat 
which  inconveniences  a  good  many  people  owed  its  origin  to  a 
congenital,  often  hereditary,  structure  of  body.  The  peculiari- 
ties of  this  structure  of  body  are  most  manifested  in  the  functions 
of  the  assimilating  organs,  especially  in  the  intestinal  absorbents, 
which  are  more  active  than  is  consistent  with  the  size  of  the 
body,  and  which  arc  mostly  concerned  with  the  osmosis  of  olea- 
gino\is  particles.  It  is  impossible,  of  course,  to  demonstrate 
during  life  this  important,  perhaps  the  most  important,  peculi- 
arity. But  there  are  others  which  are  capable  of  being  made 
subjects  of  observation,  and  these  I  endeavored  to  base  upon 
fact  by  a  table  of  the  cases  of  thirty-eight  obese  persons  then 
alive,  or  at  least  alive  when  the  lectures  were  given,  and  rang- 
ing in  weight  from  about  sixteen  up  to  thirty-six  stone  (504  lb.). 

From  this  table  I  drew  the  following  deductions: 

1.  That  in  corpulent  persons  the  bony  framework  of  the  body 
is  less  massive  than  in  the  spare,  as  indicated  by  the  smallness 
of  their  hands  and  feet. 

2.  That  the  skin  is  usually  fresh-colored  and  thin,  and  the 
hair  soft  and  fine. 

3.  That  in  youth  and  middle  age  their  digestive  apparatus 
performs  its  task  with  rapidity.  The  action  of  the  bowels  is 
generally  natural,  and  in  some  cases  loose.  But  where  the  ac- 
cumulation of  fat  is  principally  in  the  omentum,  a  pendulous 
state  of  abdomen  is  apt  to  be  produced,  causing  a  displacement 
of  the  intestinal  canal,  thus  making  it  sluggish  and  irregular. 

4.  That  their  respiratory  function  presents  a  Avell-marked  and 
universal  peculiarity.    The  volume  of  air  which  they  are  capable 


CORPULENCE.  581 

of  containing  in  and  expiring  from  their  chest  is  considerably 
less  than  the  average  quantity  contained  and  expired  by  healthy 
persons  of  equal  height.  The  lungs,  instead  of  holding  an  amount 
of  air  proportioned  to  the  size  of  the  body,  seem  of  diminished 
power.  "  Thus  the  vital  capacity  of  H.  T.  (No.  35)  a  man  of 
enormous  muscular  strength,  and  in  his  youth  remarkable  for 
his  power  of  wind,  ought  to  have  been  at  least  250  cubic  inches ; 
instead  of  that  it  is  but  205.  Ch.  S.  (No.  9)  held  but  120  cubic 
inches  of  air,  whereas  she  ought  to  have  contained  206,  accord- 
ing to  the  table  of  healthy  averages  published  by  Dr.  Hutchin- 
son. G.  0.  R.  (No.  18)  when  in  perfect  health,  in  1845,  held 
255  instead  of  270  cubic  inches."  The  lungs  therefore  in  obese 
persons  are  small,  and  consequently  their  exhalation  of  carbon 
deficient. 

5.  That  the  reproductive  powers  are  by  no  means  defective, 
some  being  very  fertile  and  few  barren. 

6.  That  a  tendency  to  obesity  is  decidedly  hereditary;  though 
the  actual  disease  is  not  always  developed  in  every  member  of 
the  family,  and  rarely  before  adult  age. 

7.  That  of  the  exciting  causes  in  those  predisposed  to  it,  none 
appears  so  common  as  the  occurrence  of  an  acute  attack  of  ill- 
ness. Next  common  are  surgical  injuries,  and  next  chronic 
diseases  of  such  nature  as  to  render  confinement  needful  without 
injuring  the  digestive  powers. 

8.  The  habitual  ingestion  of  a  large  quantity  of  liquid,  of  any 
description,  is  another  frequent  cause  of  corpulence.  Of  course 
if  the  liquid  be  fatty  at  the  same  time,  such  as  in  the  case  of 
milk,  still  more  striking  efi"ects  are  produced.  And  the  mixture 
of  alcohol  and  sugar,  such  as  we  find  in  beer  and  sweet  wines, 
makes  an  equally  deleterious  drink. 

9.  Deficiency  of  sunlight  has  a  similar  effect.  There  is  a  case 
in  the  table  (No.  13)  of  a  man  employed  in  the  cellars  of  a 
brewery,  who,  in  spite  of  strict  temperance,  found  his  bulk  be- 
coming so  great  as  to  give  him  much  alarm.  He  obtained  a 
situation  as  clerk  in  the  same  establishment,  and  found  the  em- 
ployment above  ground  cause  a  rapid  reduction. 

It  would  appear  then  from  what  has  been  said  that  the  accu- 


582  CORPULENCE. 

mulation  of  fat  in  the  tissues  is  a  partial  and  comparative  hyper- 
trophy— comparative,  that  is,  with  the  proportions  of  the  other 
functions — connected  with  a  comparative  deficiency  of  the  de- 
carbonizing force  of  the  lungs  at  least,  and  possibly  of  other 
organs. 

Hence  we  may  deduce  the  principles  of  treatment  shown  to 
be  rational  by  physiology  and  efficient  by  experience. 

1.  The  dietary  must  be  made  the  special  object  of  care ;  it 
must  be  habitually  different  from  that  of  ordinary  healthy 
persons,  inasmuch  as  the  obese  differ  congenitally  from  others. 

2.  All  oleaginous  articles  of  food  should  be  rigorously  ex- 
cluded from  the  dietary ;  oil,  fat,  butter,  milk,  cream,  maize, 
and  the  like,  must  be  entirely  abstained  from.  Sugar  too  must 
be  left  off,  and  the  amount  of  other  hydrocarbons  be  reduced  to 
a  minimum ;  starch,  in  the  form  of  potatoes,  bread,  &c.,  being 
looked  upon  with  extreme  suspicion,  for  as  previously  shown 
they  are  almost  equivalent  to  fat. 

3.  To  avoid  the  transformation  into  fat  of  starchy  articles  of 
diet,  which  it  is  impossible  wholly  to  shun,  it  is  desirable  that 
food  should  lie  in  the  stomach  as  short  a  time  as  possible,  in 
order  that  a  fatty  fermentation  (so  to  speak)  may  not  be  set  up 
in  it.  Therefore  very  light  meals  should  be  taken,  at  not  too 
long  intervals  and  at  times  most  favorable  to  rapid  digestion, 
consisting  of  substances  easy  of  solution  and  assimilation. 

4.  Liquid  should  be  taken  at  the  end  of  the  meal,  so  as  not 
to  impede  the  mixture  of  the  gastric  juice  with  the  mass. 

5.  The  liquid  taken  should  be  in  small  quantity. 

6.  Inasmuch  as  excess  of  alcohol  diminishes  the  excretion  of 
carbon  (as  shown  by  Booker's  experiments)  the  habitual  allow- 
ance should  be  limited  to  that  found  by  experience  in  the  case 
of  each  individual  to  quicken  the  digestion. 

7.  Exercise  should  be  persevered  in  to  sufficient  extent  fully 
to  employ  the  muscles  and  lungs.  But  it  should  not  exhaust 
completely  the  strength,  otherwise  an  imperfection  of  digestive 
powers  is  the  result. 

8.  The  exercise  should  be  in  the  open  air  and  sun-light. 


CORPULENCE.  583 

9.  As  in  the  management  of  all  congenital  tendencies,  medi- 
cines must  be  looked  upon  as  wholly  secondary  to  regimen. 
Those  adopted  should  be  such  as  tend  to  increase  the  metamor- 
phosis of  fat  and  its  habitual  evacuation  in  the  form  of  carbonic 
acid. 

10.  The  quality  of  the  food  is  of  more  direct  importance  than 
its  quantity. 

The  hourly  watch  over  the  instinctive  desires,  which  must  be 
observed  by  one  desirous  of  reducing  his  corpulence  makes  it  a 
serious  thing  to  advise  the  undertaking  of  the  necessary  regimen. 
Many  of  us  shirk  giving  our  advice,  because  we  feel  confident 
that  the  patient  has  not  strength  of  mind  to  follow  it.  lie  that 
commences  it  must  be  taught  to  view  himself  as  his  worst 
enemy.  Like  Epictetus'  philosopher,  he  must  "  mount  guard 
and  plot  against  himself."  We  must  feel  very  sure  we  are 
doing  what  is  right  before  we  take  such  a  responsibility,  other- 
wise hesitation  will  produce  wavering,  and  wavering  shake  the 
confidence  of  the  patient,  and  all  hope  of  benefit  be  lost.  All 
advantages  should  be  taken  of  adventitious  circumstances  to  add 
importance  to  the  enforcement  of  the  rules ;  they  should  be 
written  out  clear  and  exact,  and  enjoined  as  strictly  as  if  they 
were  moral  precepts.  If  left  to  general  and  verbal  instruction, 
their  chance  of  being  observed  is  small  indeed. 

At  the  same  time  the  dietary  prescribed,  and  the  hours  fixed 
for  meals  should  not  be  such  as  it  is  impossible  for  men  actively 
engaged  in  business  to  submit  to.  In  detail  you  may  lay  down 
some  such  scheme  as  this: 

Breakfast  to  be  taken  early  and  to  form  a  substantial  meal, 
so  as  to  prepare  for  the  day's  work.  The  solid  part  of  it  to 
consist  of  two  mutton  chops  with  the  fat  carefully  removed, 
grilled  or  plainly  cooked,  and  captain's  or  ship  biscuit.  Some- 
times a  pigeon,  a  bit  of  game,  or  a  fish  of  about  the  same  weight, 
may  be  substituted  for  the  mutton  chops.  For  liquid  to  follow, 
if  the  patient  will  take  soda-water  or  plain  water  so  much  the 
better.  If  he  cannot  get  over  his  craving  for  a  cup  of  tea,  let 
him  take  it  in  the  Russian  fashion  with  a  thick  slice  of  lemon 
floating  on  the  top  instead  of  milk. 


584  CORPULENCE. 

Lunchpon  ut  one  o'clock  may  consist  of  the  same  ingredients; 
only  instead  of  so  nincli  liquid,  a  glass  of  half  and  half,  sound 
claret,  or  burgundy  and  water  is  more  agreeable  as  well  as  more 
wholesome. 

Dinner  to  be  taken  earlier  than  is  usual  now-a-days.  Six 
is  the  best  hour.  Soup  and  fish  must  be  eschewed,  and  plainly 
cooked  mutton  and  beef,  especially  the  former,  made  the  staple 
of  the  meal.  A  bit  of  biscuit  may  accompany  it,  and  as  vege- 
tables, those  which  contain  much  insoluble  chlorophyll  and  little 
starch,  as  cabbage,  lettuce,  spinach,  French-beans,  or  celery  in 
small  qu;intity;  but  no  potatoes.  In  short  the  dinner  should 
be  as  much  as  possible  that  of  a  carnivorous  animal.  Sweets, 
pastry,  eggs,  and  beer,  must  be  avoided  like  poison.  Next  to 
water,  claret  is  the  best  drink ;  champagne  (according  to  the 
well-known  writer  on  this  subject,  M.  Dancel)  the  worst.* 

Here  should  end  the  serious  feeding  for  the  day.  A  cup  of 
Russian  tea,  or  a  Avater-ice  may  be  taken  during  the  evening, 
but  a  glass  of  water  or  soda-water  is  better. 

The  emptiness  or  sinking  at  the  pit  of  the  stomach  felt  by 
those  who  begin  a  diminished  diet,  and  which  they  often  are 
tempted  to  remove  by  eating  and  often  (still  worse)  b}'  drinking, 
is  best  relieved  by  chewing  a  bean  or  two  of  coffee.  A  supply 
sufficient  for  current  wants  may  be  carried  in  the  waistcoat 
pocket. 

I  do  not  think  it  advisable  to  burden  the  conscience  of  the 
patient  by  prescribing  dogmatically  the  number  of  ounces  of 
each  food  which  should  be  consumed.  The  nature  has  been 
shown  to  be  of  more  importance  than  the  exact  quantity  of  the 
food,  and  the  exhibition  made  by  eating  from  scales  is  annoying 
to  touchy  persons. 

Some  persons  are  able  to  do  without  the  dinner  at  all,  and 
indeed  in  1850  I  was  inclined  to  urge  the  adoption  of  this  plan, 

*  M  Dancel  cites  an  instance  of  a  young  lady  who,  with  the  intent  of  pre- 
serving her  symmetry,  fasted  four  days  every  week  upon  champagne  und  "  mar- 
rons  glacees"  alone.  Her  outline  grew  out  of  aU  drawing  with  frightful  rapidity. 
But  she  regained  it  on  resuming  a  more  rational  diet. 


CORPULENCE.  535 

and  to  substitute  for  it  biscuits  and  water  taken  standing  up  or 
while  walking  about.  This  is  not  a  scale  of  diet  absolutely  un- 
attainable. A  retired  butcher  and  pugilist  whose  case  I  tabu- 
lated (No.  35)  had  adopted  it  for  some  years  with  the  greatest 
comfort  to  himself.  He  was  able  upon  it  to  work  in  a  most 
violent  manner  in  a  small  garden  he  cultivated  for  himself  in 
the  suburbs.  He  had  reduced  himself  at  the  time  I  saw  him 
from  20  to  17  stone;  whereas  his  brother,  who  had  not  the 
same  strength  of  mind,  had  increased  to  23  stone.  Persons  of 
more  refined  education  have,  or  ought  to  have,  the  same  power 
over  their  appetites.  J.  R.  (No.  7)  by  it  reduced  himself  from 
22  to  18  stone,  and  has  sometimes  brought  himself  down  to  17. 
So  that  if  the  rapid  reduction  of  weight  be  important,  I  think 
you  may  fairly  require  dinner  to  be  abstained  from. 

It  is  not,  however,  always  desirable  to  reduce  the  weight  com 
pletely  and  rapidly. 

In  all  persons  there  is  a  certain  weight,  to  be  found  by  ex- 
perience, called  by  trainers  "the  fighting  weight,"  necessary  to 
full  force,  and  to  be  lighter  than  this  often  tends  to  injury  of 
body  and  mind.  And  I  must  also  say  that  mental  workers 
do  not  bear  abstinence  so  well  as  bodily  workers,  and  that  I  do 
not  think  it  advisable  for  a  man  whose  mind  is  much  engaged  to 
attempt  the  omission  of  the  usual  evening  meal. 

As  to  more  strictly  pharmacopoeial  remedies  I  have  found  full 
doses  of  liquor  potassae  at  the  beginning  of  the  treatment  very 
beneficial,  especially  in  persons  who  are  incapacitated  by  bodily 
infirmity  from  taking  full  exercise.  I  presume  that  it  acts  by 
increasing  the  vital  powers  of  metamorphosis,  by  saponifying 
in  part  the  fat  contained  in  the  blood  and  enabling  it  to  be  burnt 
off  as  carbonic  acid. 

Where  the  size  of  the  abdomen  impedes  the  walking,  a  belt, 
such  as  pregnant  women  wear,  is  useful.  A  few  sweating  baths 
are  also  beneficial  at  the  commencement,  as  they  bring  the  skin 
into  good  condition;  but  as  an  habitual  resource  they  are  de- 
bilitating. 

Of  iodine  and  vinegar  I  have  no  good  to  say.     The  moderate 


586  CORPULENCE. 

use  of  the  former  certainly  does  not  cause  the  disappearance  of 
healthy  fat.  Indeed,  it  has  been  noticed  by  Lugol,*  and  is 
matter  of  daily  observation  at  our  metropolitan  hospitals,  that 
patients  frequently  acquire  a  considerable  amount  of  embon- 
point during  the  time  they  are  taking  it.  The  cases  of  tumors 
and  of  fat  are  very  distinct.  As  Dr.  Pereira  remarks, f  "  The 
enlargements  which  these  agents  (mercury  and  iodine)  remove 
are  not  mere  hypertrophies ;  their  structure  is  morbid,  and  they 
must  in  consequence  have  been  induced  by  a  change  in  the 
quality  of  the  vital  activity;  in  other  words  by  morbid  action. 
Medicines,  therefore,  which  remove  these  abnormal  conditions, 
can  only  do  so  by  restoring  healthy  actions."  But  the  action 
which  causes  the  deposition  of  fat  in  the  adipose  tissue,  is  of  a 
healthy  nature,  and  harm,  rather  than  benefit,  is  to  be  expected 
from  the  medicines  under  discussion ;  that  harm  which  always 
accrues  from  a  valuable  remedy  wrongly  employed. 

Vinegar  seems  to  produce  thinness  by  injuring  the  digestion, 
and  thus  preventing  the  absorption  of  adipose  matters.  This 
clearly  is  a  risk  not  worth  running  for  the  sake  of  the  possible 
benefit.  No  elegance  of  outline  or  even  comfort  in  work  can 
repay  one  for  a  chronic  dyspepsia. 

Of  diuretics,  which  are  recommended  by  the  elder  physicians, 
I  have  no  experience.  But  as  there  is  less  fatty  matter  excreted 
by  the  kidneys  than  by  any  other  gland,  they  do  not  seem  to 
promise  well. 

The  prognosis  of  obesity  depends  very  closely  upon  the  age  at 
which  it  has  commenced.  To  that  form  of  the  disease  which 
begins  at  birth,  and  goes  on  increasing  during  infancy  and 
childhood  cure  is  unattainable.  It  is  a  sort  of  monstrosity,  and 
the  subjects  of  it  usually  display  some  other  bodily  malformation 
or  a  deficiency  of  intellect.  When  it  begins  in  childhood  or 
about  the  time  of  puberty,  we  must  not  be  deterred  by  the  cir- 
cumstance of  its  being  hereditary  from  trying  to  remedy  the  in- 
convenience.    We  cannot  truly  reduce  our  patients  entirely  to 

*  "  Essays,"  translated  by  Dr.  O'Shaughaeasy. 
f  "Materia  Medica,"  vol.  i,  p.  196  (edit.  1848). 


CORPULENCE.  587 

tlie  average  size  and  weight,  but  we  may  enable  them  to  pass 
life  in  comfort  and  usefulness. 

The  later  the  disease  begins,  the  more  controllable  it  is  by 
management ;  until  the  prime  of  life  is  passed,  and  then  old  age 
impedes  in  some  degree  the  benefit  we  may  confer,  not  by  ren- 
dering our  measures  inert,  but  by  preventing  our  employing 
them  quite  so  actively  as  we  should  have  done  at  an  earlier 
period. 


LECTURE   XLIX. 

ON    PEP  SINE. 

History  of  the  use  of  gastric  juice  in  meclicine — Difficulties  of  its 
use  obviated  by  preparation — Experience  of  its  use  in  a  few 
typical  cases — Limits  of  advantages  gained — Details  of  ad- 
ministration. 

[Extra  course,  St.  Mary' s,  Summer  Session,  1857.) 

The  attempt  to  turn  the  peculiar  power  of  gastric  juice  to  ad- 
vantage dates  from  remote  antiquity.  Pliny  mentions  the  fluids 
of  the  stomach  of  sucking  animals  as  in  common  use  for  a  variety 
of  purposes,  such  as  curing  disorders  of  the  intestines,  allaying 
the  inflammation  from  spiders'  bites,  stopping  bleeding  from  the 
nose,  preventing  snakes  attacking  you,  and  in  short  against 
poisons  in  general.*  To  come  to  more  medical  matters,  Ascle- 
piades  recommended  it  as  a  means  of  dissolving  milk  which  has 
clotted  in  the  stomach  in  dangerous  excess. f  Galen,  arguing 
probably  on  his  physiological  theories,  attributes  a  "digestive" 
and  "  drying"  power  to  it.  But  he  also  mentions  having  felt 
in  his  own  person  the  relief  aff'orded  by  it  to  weight  at  the  epi- 
gastrium after  drinking  too  much  milk,  and  advises  a  trial  of  it 
in  abdominal  disorders.  He  remarks  that  the  stomach  of  one 
animal  diff"ers  from  another  only  in  degree  of  power.  He  gives 
a  warning  that  the  boiling  temperature  destroys  its  virtues,  as 
we  now  well  know  ;  for  he  found  that  hens'  and  cormorants' 
stomachs,  when  cooked,  were  perfectly  inert. J 

*  See  the  places  referred  to  in  any  good  index  to  Pliny's  "  Naturalis  Historia," 
article  "  Coagulum." 

f  Quoted  in  "  Galen  on  Antidotes,"  ii,  7. 

I  "  Galen  on  Simple  Medicines,"  x,  11  ;  xi,  13. 


ON  PEPSINE.  589 

On  the  strength  of  Galen's  very  rational  advice  the'coagulated 
milk  and  fluid  taken  from  the  paunches  of  several  young  animals 
was  a  remedy  suiBciently  often  used  to  retain  a  place  in 
European  pharmacopoeias  up  to  the  first  quarter  of  the  last  cen- 
tury. This  is  the  explanation  given  by  Dr.  Schroder,  a  Dutch 
pharmacologist,  who  wrote  in  1672,*  of  the  method  of  prepar- 
ing, and  the  reason  for  using,  '■'■Coagulum  leporis,f  Juvdi,  agyii, 
equi,''  &c. 

The  disagreeable  nature  of  the  remedy  in  this  form  probablv 
drove  it  out  of  use,  for  the  last  London  pharmacopoeia  in  which 
it  appears  is  that  of  1677.  In  the  edition  of  1721,  the  only  re- 
presentative of  gastric  juice  is  the  mucous  membrane  of  the  hen's 
stomach — "  Pelliculse  stoinacM  gallinse  int,eriores.''X  In  1746 
this  also  had  vanished,  along  with  "  stercus  bovinum,  kumaniim^ 
pavonis,"  and  various  similar  remedies  which  patients  had  got 
too  civilized  to  submit  to,  without  at  least  knowing  the  reason 
why.  Thirty  years  later,  the  immortal  experiments  of  the 
Abb^  Spallanzani  threw  a  bright  new  light  into  the  subject  of 
digestion,  and  taught  the  true  nature  of  the  gastric  juice.  With 
much  juster  views  than  of  old  its  use  in  medicine  was  again  re- 
commended. Dr.  Mongiardini  of  Pavia,  a  pupil  of  Spallanzani's, 
at  his  master's  instance  treated  indigestion  successfully  with  the 
gastric  juice  of  crows.  Another  pupil  employed  it  as  a  lithon- 
triptic,  to  break  down  calculi  by  destroying  the  animal  matter 
which  holds  them  together.  M.  Senebier,  a  clerical  pupil,  sug- 
gested that  its  antiseptic  power  might  make  it  useful  in  surgery, 

*"  Pharmacopoeia  Aledico-Chemica."     Amstelodarui,  1672. 

f  The  rennet  of  the  leveret  is  now  usually  wasted,  but  the  Roman  dairymaids 
preferred  it  to  that  of  any  other  animal  for  making  cheese.  Varro  ranks  it  as 
the  best,  then  that  of  the  kid,  then  of  the  lamb.  (Varro  de  '•  Re  Rusticil,"  lib.  ii, 
xi,  4).  The  Roman  physicians  also  had  the  same  preference.  Sammonicus,  in 
a  prescription  for  "  Coins"  (Colic),  says,  "  Aut  pavidi  leporis  madefacta  coagula 
pota."  ("  Quiuti  Sereni  Sammonici  de  Medicina  Pra3cepta,"  "  De  Colo  compes- 
cendo.'")  This  accounts  for  its  being  named  in  pharmacopoeias  which  omit  other 
rennets,  as  for  instance  in  the  Vienna  priced  drug  list  of  1613  and  1646,  in  which 
its  price  varies  from  six  to  sixteen  kreutzers  the  half  ounce. 

I  This  is  another  Italian  expedient  for  coagulating    milk   rarely  used  now. 
Palladius  recommends  it  for  making  summer  cheeses,  when  you  cannot  get 
leveret's  rennet.     ("  Palladius  de  Re  Rustica,"  "  Meusis  .Maius,"  ix.) 
38 


590  ON  PEPSINE. 

and  advised  a  trial  of  sheep's  paunch  as  an  application  to  ill- 
conditioned  wounds.*  M.  Bojer,  of  Strasburg,  found  that  it 
destroyed  the  poison  of  the  viper,  and  thought  it  might  be  an 
antidote  to  snake  bites. f 

With  all  the  obvious  advantages  with  which  the  remedy  re- 
commended itself  to  the  physician,  there  Avas  the  insurmountable 
difficulty  of  obtaining  it  in  a  form  fit  for  general  use  internally. 
It  was  of  course  necessary  to  administer  it  at  the  same  time 
with  the  food,  and  any  nauseating  substance  then  given  does 
more  harm  than  good  by  taking  away  the  already  squeamish 
appetite.  Dr.  Latham,  who  practiced  in  Paris  some  years  ago, 
informed  me  that  M.  Laennec  had  a  preparation  of  concentrated 
gastric  mucus,  which  he  recommended  with  great  enthusiasm  ; 
and  Dr.  Handfield  Jones  at  this  hospital  gave  in  some  cases  a 
cold  infusion  of  pig's  stomach,  acidulated  with  muriatic  acid. 
In  this  form,  however,  the  remedy  is  disagreeable  and  inele- 
gant. 

But  the  matter  showed  itself  in  quite  a  new  light  when  an  in- 
genious French  pharmacien,  M.  Boudault,  at  the  instigation  of 
Dr.  Corvisart.^  made  the  very  elegant  and  agreeable  preparation, 
called  ^^  Poiidre  nufrimentive."  It  is  simply  pepsine  from  the 
sheep's  stomach  dried  on  starch,  with  lactic  acid  added  or  not 
according  to  circumstances.  You  have  during  the  past  winter 
(of  1856-7)  seen  me  prescribe  it  to  numerous  patients  in  the 
w'ards,  and  I  have  also  employed  it  frequently  in  pi'ivate  prac- 
tice, so  that  I  think  we  are  in  a  position  now  to  form  an  idea  of 
its  value  to  the  practical  physician. 

These  hospital  cases  in  which  I  have  administered  it  with  ad- 
vantage are,  six  of  phthisis  pulmonalis,  one  of  cancer  near  the 
pylorus,  two  of  gastric  ulcer,  one  of  hysterical  vomiting,  two  of 
nausea,  one  of  hysterical  pain  after  eating,  two  of  atonic  pain 
after  eating,  one  of  atonic  gout,  one  of  dilated  stomach,  one  of 
gastric  flatulence,  three  of  low  fever,  and  two  of  pneumonia. 
In  these  the  full  benefit  which  physiological  reasoning  would  lead 
us  to  expect  from  the  remedy  has  followed. 

*  "  Experiences  sur  la  Digestion  de  THomme,  par  I'Abbe  Spallanzani,  avec  dea 
Considerations,''  &c.,  par  Jean  Senebier.     Geneve,  1783. 
f  Falck  "  Handbuch  der  Arzneimittellehre,"  vol.  i,  p.  275. 


ON  PEPSINE.  591 

[These  cases  fairly  represent  my  later  experience  of  the 
remedy,  if  my  memory  serves  me  right,  but  I  regret  to  say  I 
have  not  preserved  notes  of  trials  made  of  late  years.] 

I  have  also  injected  it  per  anum,  mixed  with  food,  in  a  case  of 
ulcerated  oesophagus,  and  in  a  case  of  manio-hysterical  vomiting 
and  dysphagia.  But  in  neither  did  it  appear  to  delay  death. 
Probably  the  patients  were  already  too  far  gone. 

Several  other  cases  of  atonic  pain  after  eating,  in  which  I 
have  given  pepsine,  I  have  not  since  heard  of,  but  probably 
should  have  done  so  had  any  harm  happened. 

In  one  case  of  chronic  dysentery  it  was  stated  to  cause  nausea 
and  loss  of  appetite.  In  one  case  of  consumption,  and  in  one  of 
pendulous  tumor  of  the  abdomen,  it  purged  the  patient.  These 
are  the  only  instances  of  inconvenience  that  I  have  been  able  to 
connect  with  the  administration  of  the  remedy. 

The  phthisical  cases  have  been  those  where  a  progressive 
anaemia  was  accompanied  by  an  inability  to  digest  meat  or  other 
albuminous  food.  This  inability  is  exhibited  in  three  ways: 
first,  by  meals  of  such  diet,  even  in  very  small  quantities,  being 
followed  by  a  sense  of  great  weight  and  oppression  at  the  epigas- 
trium, and  sometimes  by  actual  vomiting ;  secondly,  by  the  pas- 
sage of  loose  fetid  stools  containing  much  unaltered  muscular 
fiber,  lumps  of  fat,  and  such  like  remnants  of  a  recent  meal ; 
thirdly,  by  entire  loss  of  appetite  and  an  instinctive  nausea 
roused  by  the  bare  idea  of  flesh  food.  Often  all  three  phe- 
nomena exist  together ;  but  each  one  may  be  found  separately, 
and  is  of  itself  a  sufficient  indication  of  the  patient's  state. 

The  state  of  the  stomach  when  these  symptoms  occur  is  pro- 
bably an  excessive  secretion  in  the  upper  part  of  the  alimentary 
canal  of  alkaline  mucus,  which  envelopes  the  food,  and  prevents 
the  action  of  the  gastric  juice  upon  it.  The  consequence  is, 
either  its  rapid  ejection  unaltered,  or  its  decomposition,  and  the 
evolution  of  fetid  gas.  If  vegetable  food  be  mixed  with  the  meat, 
it  ferments  into  acetic  acid,  and  thus  you  may  have  sour  eructa- 
tions from  the  stomach,  and  diarrhsea  arising  out  of  the  want  of 
gastric  juice.  If  this  excessive  secretion  of  mucus  is  recent  and 
moderate,  the  appetite  may  remain  uninjured,  nay,  may  some- 


592  ON  PEPSINE. 

times  be  morbidly  increased  ;  but  a  long  continuance  joined  to 
progressive  pulmonary  disease,  is  sure  to  induce  an  anoemic 
condition  of  the  alimentary  canal,  which  results  in  a  disgust 
for  food. 

Now  this  state  of  things  it  is  very  important  to  check.  If  it 
goes  on,  the  patient  cannot  take  in  suflBcient  quantities  the  meat 
which  should  refresh  his  degenerating  muscles  and  pale  blood ; 
he  cannot  take  the  cod-liver  oil  which  is  to  replace  his  emaci- 
ating tissues ;  he  cannot,  from  weakness,  take  the  exercise  which 
might  renew  his  whole  diseased  system.  And  I  do  not  know  any 
remedy  which  more  readily,  obviously,  and  directly  does  what  it 
can  towards  checking  such  a  state  than  pepsine.  It  acts  imme- 
diately and  surely. 

You  must  not,  however,  raise  your  expectations  of  the  power 
of  pepsine  too  high,  or  you  will  be  disappointed.  I  said  just  now 
it  "does  what  it  can,"  and  I  would  have  you  understand  clearly 
what  position  this  agent  holds  in  the  rational  materica  medica, 
and  then  you  will  know  what  good  results  you  may  demand  with 
reasonable  hopes  of  obtaining  them.  It  is  an  artificial,  and 
therefore  a  partial,  substitute  for  a  natural  process.  Gasti'ic 
juice  prepared  by  a  healthy  animal  is  mixed  with  the  food,  in- 
stead of  that  which  the  patient's  stomach  ought  to  prepare. 
And  it  acts  in  the  body  just  as  it  would  out  of  the  body  under 
the  same  circumstances  of  heat  and  motion.  The  chewed  meat 
is  dissolved  by  it  just  as  you  see  the  white  of  egg  suspended  in 
this  beaker  dissolved  by  it ;  and  the  putrefactive  process  is 
arrested  by  it  in  the  intestinal  canal  just  as  you  perceive  the 
putrefactive  process  is  arrested  by  it  in  the  experiment  under 
our  eye.  For  you  may  observe  that  this  albumen  suspended  in 
pepsine  is  quite  sweet,  whereas  that  soaked  for  the  same  time  in 
saliva  is  most  fetid.  It  is,  therefore,  a  substitute  for  the  natural 
secretion,  and  to  a  certain  extent  supplies  its  place. 

But  like  all  imitations  of  nature,  it  is  coarse  and  imperfect. 
The  solvent,  instead  of  being  gradually  and  continuously  poured 
on  to  the  outside  of  the  mass  of  food,  is  mixed  up  in  the  middle 
part  of  it,  and  acts  merely  chemically,  without  any  of  the  me- 
chanical and  physiological  helps  belonging  to  natural  digestion, 


ON  PEPSINE.  593 

and  consequently  soon  exhausts  its  energies.  The  chyme,  or 
albumen  prepared  for  absorption,  instead  of  being  wiped  off  and 
swept  away  by  the  stomach,  remains  for  some  time  mixed  up  with 
the  pepsine,  so  that  the  latter  is  not  freed  for  the  solution  of  a 
new  portion.  By  this  imperfect  process  only  a  very  small  por- 
tion of  meat  can  be  dissolved  at  once. 

Hence,  if  you  hope  that  by  administering  pepsine  with  it,  you 
can  get  a  full  and  sufficient  meal  eaten  at  once  by  your  consump- 
tive patient,  you  will  fail  in  your  expectations.  Give  half  a 
mutton  chop  with  the  remedy  the  first  day;  and  if  that  is  digested 
well,  next  day  a  whole  chop  ;  but  then  you  have  got  to  the  end 
of  your  tether,  and  the  digestion  of  a  larger  :j[uantity  will  not 
be  at  all  assisted  by  artificial  solvents.  After  a  chop  has  been 
digested  and  absorbed  twice,  or  even  once  a  da}'^  by  this  means 
for  about  a  week  or  ten  days,  the  expedient  has  probably  done 
all  the  work  that  can  be  fairly  asked  of  it,  and  the  stomach  has 
either  recovered  sufiicient  energy  to  digest  alone,  or  will  require 
different  remedies  to  enable  it  to  do  so. 

Therefore,  for  the  pepsine  to  be  completely  successful  in  these 
cases — first,  it  must  be  given  only  to  those  who  cannot  digest 
half  a  mutton  chop  without  it ;  secondly,  more  than  a  chop  must 
not  be  given  at  once ;  thirdly,  it  must  not  be  required  to  go  on 
alone  improving  the  patient's  condition  for  more  than  a  week  or 
ten  days. 

But  for  the  time  named  I  advise  its  being  given  alone,  and  the 
action  not  interfered  with  in  general  by  other  medicines.  Many 
will  really  prevent  its  chemical  effect,  and  all  will  confuse  your 
judgment  of  the  advantage  gained.  In  this  time  you  will  gene- 
rally find  that  the  repugnance  of  the  patient  to  meat  has  been 
overcome,  and  that  a  small  quantity  of  it  at  a  time  can  be  re- 
lished and  digested ;  the  morbid  fetor  of  the  stools  diminishes, 
and  the  flatulence  and  distress  arising  during  their  passage 
through  the  bowels  ceases.  A  renewed  strength  and  a  renewed 
power  of  assimilation  commences,  the  sleep  becomes  more  natural, 
with  the  diminution  of  night  sweats  and  hectic ;  while,  at  the 
same  time,  the  pulmonary  symptoms  of  cough,  dyspnoea,  &c., 
relax,  and  a  step  at  any  rate  is  taken  in  the  right  direction  to- 


594  ON  PEPSINE. 

wards  the  cure  of  the  disease.  It  is  remarkable,  too,  what  a 
slight  improvement  in  the  digestive  powers  will  often  enable  the 
patient  to  take  iron  and  cod-liver  oil.  These  are,  you  know,  the 
mainstays  in  the  treatment  of  tubercular  consumption,  and  any 
expedient,  however  temporary,  which  will  pave  the  way  for  their 
administration,  is  a  great  boon. 

It  would  not  suit  the  plan  of  the  present  lectures  to  quote  in 
detail  these  consumptive  cases.  They  differ  much  from  one 
another  in  their  unessential  characters — namely,  in  the  stage 
and  general  phenomena  of  the  disease,  in  age  and  sex  of  the 
patients  ;  while  they  all  closely  resemble  one  another  in  essen- 
tial points — that  is  to  say,  in  those  which  I  have  described  as 
indicating  a  mucous  condition  of  stomach,  preventing  the  gastric 
juice  being  poured  out  on  the  food,  and  finally  leading  to  angemia 
and  atrophy  of  the  secreting  membrane.  They  resemble  one 
another  also  in  exhibiting  an  immediate  and  uniform  ameliora- 
tion of  limited  extent.  In  one  man  who  had  lost  his  voice,  appa- 
rently from  crude  tubercle  in  the  lungs,  with  ulcerated  trachea, 
the  amelioration  of  vocal  power  and  of  the  cough  continued  so 
long,  that  I  let  him  remain  three  weeks  taking  pepsine  alone ; 
but,  then,  he  also  continued  to  improve  more  afterwards  on  cod- 
liver  oil,  so  that  he  might  just  as  well  have  commenced  it  sooner. 
In  another,  who  had  tubercular  ulcers  in  the  bowels,  afterwards 
fatal,  there  was  an  idea  that  the  pepsine  caused  a  relapse  of 
diarrhoea ;  but  I  suspect  the  coincidence  was  accidental.  These 
are  the  only  cases  where  it  appeared  to  do  more  good  or  less 
good  than  I  have  expected  of  it. 

The  case  I  alluded  to  of  cancer  near  the  pylorus  is  an  instance 
of  a  disease  necessarily  fatal  being  still  worthy  of  the  careful 
attention  of  the  medical  man.  When  the  patient  came  under 
my  care,  she  was  unable  to  keep  anything  at  all  on  her  stomach; 
every  solid,  even  an  ounce  of  beef-tea  was  vomited  unchanged 
within  half  an  hour  of  its  ingestion.  She  had  been  taking 
prussic-acid,  soda,  creasote,  opium,  &c.,  without  benefit,  and  was 
dying  rapidly  of  starvation.  I  ordered  her  immediately  half  a 
mutton  chop  with  fifteen  grains  of  Boudault's  "poudre  nutrimen- 
tive  "  twice  a  day,  and  an  ounce  of  milk  and  lime-water  every 


ON  PEPSINE.  595 

two  hours.  She  kept  all  that  down ;  it  passed  the  pylorus,  and 
nourished  her  so  far  that  she  had  a  good  night's  sleep,  and  the 
next  day  was  able  to  take  a  whole  mutton  chop.  So  she  went 
on  for  three  weeks  gaining  flesh,  losing  her  pain,  and  acquiring 
a  cheerfulness  about  the  future  unwarranted  by  the  gloomy  prog- 
nosis which  truth  compelled  me  to  give  her.  So  far  all  was 
right ;  reason  had  reasoned  well.  But  I  feel  it  a  duty  to  tell 
you  the  mistakes  I  make,  as  much  as  the  occasions  on  which  I 
act  wisely.  And  I  find  recorded  in  my  note-book  a  warning, 
which  I  advise  you  to  profit  by,  of  the  importance  of  "  letting 
well  alone."  The  patient  from  the  first  had  jaundice,  with  pale 
stools  and  bilious  urine ;  and  now,  I  thought,  had  sufficiently  re- 
covered strength  to  bear  an  endeavor  to  make  the  liver  clear 
the  blood  of  its  bile  a  little  more  briskly.  I  therefore  gave  her 
some  nitro-hydrochloric  acid,  which  is  often  of  great  use  under 
similar  circumstances.  But  the  result  was  most  unfortunate. 
The  vomiting  returned  with  violence.  The  acid  was  left  off,  and 
the  vomiting  stopped,  but  not  before  the  ground  gained  had  been 
lost.  Then  again,  contrary,  I  must  say,  to  my  wish,  it  was 
judged  expedient  to  give  the  patient  mercury,  and  she  rapidly 
sank.  The  jaundice  was  then  proved  to  be  dependent  on  cancer 
of  the  gall-bladder.  Now,  here  it  is  impossible  not  to  allow  that 
life  was  lengthened  by  artificial  pepsine,  and  would  have  been 
further  lengthened  but  for  a  meddlesome  propensity  in  both 
physician  and  patient  for  continuous  improvement. 

In  one  case  of  hysterical  vomiting,  and  two  of  nausea  pre- 
venting a  due  quantity  of  food  being  taken  by  hysterical  per- 
sons, this  remedy  has  appeared  to  enable  the  patient  to  swallow 
meat.  The  mere  nutriment  thus  imbibed  has  improved  the  ap- 
petite for  future  meals  ;  and  the  valerian  and  salt  sponge-baths 
afterwards  administered  seemed  to  have  a  more  rapid  effect  than 
without  it.  The  rational  explanation  of  its  good  influence  is, 
that  both  in  hysteria  and  anaemia  the  secretion  of  gastric  juice 
is  apt  to  be  irregular  and  deficient,  and  that  the  morbid  pro- 
cesses here  act,  as  is  so  often  the  case,  in  a  circle ;  the  non- 
secretion  of  gastric  juice  still  farther  starving  the  blood  and 
aggravating  the  hysteria  and  anaemia,  and  that  further  aggra- 


596  ON  PEPSINE. 

vation  again  diminishing  the  secretion.  But  once  breaking  the 
magic  chain,  and  enabling  even  a  single  meal  to  be  well  digested, 
begins  a  march  towards  health  which  it  is  comparatively  easy  to 
guide  afterwards. 

Closely  connected  with  the  last-named  complaints  is,  in  the 
female  sex,  atonic  gastralgia.  Indeed  I  may  say  it  is  practically 
identical.  At  the  same  time  that  the  gastric  juice  is  imper- 
fectly secreted,  the  muscles  of  the  stomach  refuse  to  perform 
the  peristaltic  motions  with  sufficient  activity.  Hence  not  only 
is  the  alimentary  mass  a  greater  inconvenience  than  it  ought  to 
be,  but  it  actually  lies  longer  than  usual  in  the  first  portion  of 
the  canal,  as  may  be  found  on  percussion  of  the  epigastrium. 
Atonic  gastralgia  is  a  common  consequence,  in  the  educated 
classes,  of  excessive  mental  and  sedentary  labor.  Where  this  is 
very  great,  I  have  found  pepsine  of  some  use  ;  but  in  the  slighter 
cases,  which  more  frequently  comes  before  us,  I  have  not  seen 
any  apparent  benefit  accrue  from  it.  A  change  of  habits  is 
here  the  only  permanent  cure,  but  temporarily  strychnine  is  an 
efficacious  remedy. 

In  a  case  of  diarrhoea  and  mucous  vomiting,  occurring  in  an 
old  victim  of  atonic  gout,  the  stools  became  more  natural  and  less 
frequent,  and  strength  was  regained,  on  taking  pepsine  and  mut- 
ton chops,  instead  of  opium  and  acetate  of  lead. 

As  acute  disease  has  a  habit  of  getting  well  of  itself,  it  is  not 
of  course  such  a  good  test  of  the  essential  benefit  derived  from 
remedies ;  and  only  by  comparisons  on  a  large  scale  can  one 
speak  of  fever  and  pneumonia  being  benefited  by  pepsine.  There 
seemed,  however,  in  those  cases  alluded  to,  an  immediate  im- 
provement to  take  place  in  the  appearance  of  the  tongue  and  of 
the  evacuations ;  and  it  is  impossible  not  to  think  that  the  ame- 
lioration in  the  alimentary  canal  thus  made  evident  would  tend 
to  lessen  the  mortality. 

On  the  whole,  then,  I  cannot  but  conclude  that  we  have  in 
pepsine  a  valuable  and  a  safe  remedy,  and  an  important  aid  to 
rational  medicine. 

The  mode  in  which  I  have  administered  it  has  depended  on 
the  diet  which  the  patient  is  allowed.     If  regular  meals  are 


ON  PEPSINE.  597 

eaten,  then  it  is  best  taken  spread  as  a  sandwich  between  two 
thin  slices  of  bread  at  the  commencement  of  the  dinner.  Fif- 
teen grains  of  the  starchy  powder  is  the  usual  dose  for  an 
adult.  If  the  patient  is  so  ill  that  food  is  obliged  to  be  taken 
more  frequently  and  in  small  quantities,  so  as  to  keep  up  a  con- 
tinuous supply,  smaller  doses  of  the  pepsine  powder  may  be 
mixed  in  a  draught  every  four  or  five  hours,  at  the  same  time 
with  the  food. 


LECTURE   L. 

ON   ALCOHOL. 

ExiJerhnents  showing  the  action  of  alcohol  on  the  vital  metamor- 
phosis of  the  body,  with  a  running  commentary  on  each — 
Opposite  opinions  about  the  use  of  alcohol — Best  guide  to  the- 
rapeutical use  is  physiological  observation  of  its  action  on  the 
healthy  body — What  is  a  stimulant? — The  efect  of  alcohol  is 
arrest  of  nervous  function — How  it  comes  to  be  an  indirect 
restorative — Rules  for  the  administration  of  alcohol — Form  of 
administration. 

{St.  Marys,  1861.) 

Our  school-porter  and  the  late  Mr.  Hall  Smith  assisted  me 
during  1860,  in  a  series  of  experiments  on  the  effects  of  alcohoL 
The  melancholy  circumstances  of  the  latter's  death  brought  them 
to  an  abrupt  termination,  and  made  the  prosecution  of  the  in- 
vestigations painful  to  me.  But  still  let  us  see  what  can  be  done 
with  the  facts  already  collected,  and  try  whether  they  can  be 
made  of  service  to  clinical  medicine. 

Test  I. — W.  M.  Age  thirty-eight.  Weight  254  lbs.,  taken 
at  noon  every  day.  Habits  of  life  extremely  regular.  He  walks 
half  an  hour  before  breakfast  daily ;  breakfasts  at  eight  on  two 
cups  of  coffee,  bread  and  butter,  and  a  slice  of  cold  meat ;  dines 
at  one  on  beef  and  mutton  in  regular  quantity,  potatoes,  and 
pudding  ;  has  tea  at  five,  two  cups,  with  bread  and  butter ;  sups 
at  nine,  on  bread  and  butter,  or  cheese,  with  half-a-pint  of  ale. 
He  sleeps  six  and  a  half  to  seven  hours.  His  bowels  are  open 
once  daily. 


ON  ALCOHOL. 


599 


A  view  of  the  normal  amount  of  metamorphosis  in  the  body  is 
aJBForded  by  this  table  : — 

Table  A. 


Quantity 
in   cubic 

centi- 
metres. 

Specific 
gravity. 

Urea  in 
grammes. 

Chloride 
of  sodium 

in 
gi-ammes. 

Sulphuric 
acid   in 
grammes. 

Phospho- 
ric acid 
in 
grammes. 

Uric 

acid 

in 

grms. 

Amount  of  urine  and 
its  several  parts 
made  in  23  days,  in 
perfect  health  and 
on  usual  diet      .     . 

Ditto  in  15  days*     . 

Mean  daily  amount . 

24,970 
1,085 

23-518 
1-022 

728-437 
31-671 

174-625 
7-592 

51-307 
2-230 

44-719 
1-944 

2-813 
•187 

The  ^ifect  of  the  addition  of  a  moderate  quantity  of  alcohol  to 
the  daily  meal  is  shown  by  the  next  table : — 

Table  B. 


Date. 

Quantity 
In  Ciibic 
centi- 
metres. 

Specific 
gravity. 

Urea  in 
grammes. 

Ctiloride 
of  sodium 

in 
grammes. 

Sulphuric 

acid  in 

grammes, 

Pliospho- 
ric  acid  in 

Uric   acid 

in 
grammes. 

Daily  quantity  of  best 
French  brandy  added  to 
meals  in  ounces  by  mea- 

3 

6,  viz..  U  at 
breakfast,  din- 
ner, tea,  and 
supper. 

Sep.    13 
u       14 

"       19 
'•       20 
"       21 
"       22 

1,020 
1,570 

1,050 
1,200 
1,110 

770 

1-024 
1-022 
1-026 
1-025 
'    1-023 
1-026 

30-708 
39-746 
38-795 
42-695 
37-974 
30030 

7-140 
10-990 
8-400 
9-600 
6-937 
6-160 

2-017 
2-579 
2-456 
2-622 
2-2U 
2-065 

1-469 
-848 
1-890 
1-944 
1-798 
1-386 

•  •  •  ~1 
■  ■  ■    (■ 

On  September  23  the  appetite  for  food  was  observed  to  be 
somewhat  less  than  usual,  and  the  experiment  accordingly  ceased; 
for  any  change  of  usual  weight,  health,  feeling,  or  habits,  of 
course  would  vitiate  the  result  of  an  investigation  conducted  in 
this  form. 

These  experiments  lead  to  the  belief  that  the  taking  a  mode- 
rate quantity  of  alcohol  with  food — 

{1st.)  Increase  the  quantity  of  urea  daily  excreted,  and  in  a 
much  minor  degree  that  of  the  chlorides  and  sulphates. 

{2d.)  It  does  not  increase  the  aqueous  jJfirt  of  the  urine. 

(dd.)  It  decreases  the  quantity  of  phosphates. 

*  On  eight  days  the  uric  acid  was  not  weighed. 


600  ON  ALCOHOL. 

(4:th.)  The  augmentation  is  temporary^  and  after  a  time  is  fol- 
lowed hy  a  reduction  to  the  normal  measure,  which  reduction  is 
coincident  with  a  loss  of  appetite. 

The  increase  in  the  quantity  of  urea  excreted  would  seem  to 
show  that  the  renewal  of  the  muscular  tissues,  the  appropria- 
tion of  new  flesh,  and  the  removal  of  old  flesh,  go  on  more 
actively  for  making  a  moderate  quantity  of  alcohol  part  of  the 
daily  food. 

The  non-increase  in  the  aqueous  secretion,  and  the  decrease 
in  the  phosphates,  would  seem  to  show  that  this  change  is  not 
merely  a  general  augmentation  of  the  destructive  metamor- 
phosis of  the  body ;  for  if  it  were,  the  whole  of  the  constituents 
of  the  urine  would  be  equally  aff"ected. 

In  short  the  circumstances  seem  to  indicate  that  a  moderate 
dose  of  alcohol  acts  by  temporarily  augmenting  the  digestive 
power  of  the  stomach,  helping  it  to  appropriate  more  thoroughly 
the  food. 

The  decrease  in  the  excretion  of  phosphates  is  an  interesting 
observation.  The  chief  source  of  phosphorus  in  the  urinary 
excretion  must  be  nerve  tissue,  and  it  is  assuredly  something 
more  than  a  mere  coincidence  when  a  re-agent,  whose  efi'ects 
are  most  peculiarly  manifest  on  the  functions  of  the  nerves, 
diminishes  what  we  believe  to  be  the  metamorphosis  of  that 
portion  of  the  body.  "We  can  hardly,  under  the  circumstances, 
hesitate  to  call  alcohol  an  arrester  of  nerve-life,  and  conse- 
quently a  controller  of  nervous  action  on  the  rest  of  the  frame ; 
and  it  would  be  wise  to  cast  about  for  explanations  which  would 
make  this  harmonize  with  its  other  operations. 

Test  II. — Letitia  C,  a  prostitute  aged  twenty-three,  acquired 
the  habit  during  a  year  of  her  being  on  the  town  of  frequent 
tippling  to  drown  care.  Standing  by  her  bed  at  home  on  the 
14th  of  August,  she  suddenly  fell  on  to  it,  not  losing  her  senses, 
but  having  complete  paralysis  of  the  right  leg  and  arm  without 
a  fit.  On  her  admission  to  St.  Mary's,  two  days  afterwards, 
the  power  had  returned  in  a  great  measure  to  the  limbs,  but  the 
right  lingual  and  facial  muscles  were  still  quite  paralytic.  As 
far  as  one  could  judg3  by  external  phenomena,  all   the  viscera 

/ 


ON  ALCOHOL. 


601 


except  the  brain  were  in  a  healthy  state.  She  stayed  in  the 
hospital  till  September  6,  when  she  was  offered  a  place  as 
servant,  and  a  slight  impediment  to  speech  remaining  I  con- 
sidered not  sufficient  reason  for  her  passing  over  so  good  a 
chance  of  bettering  her  social  state.  During  the  time  she  was 
under  observation  no  drugs  were  prescribed  for  her ;  she  rested 
on  her  bed  the  greater  part  of  the  day,  and  sauntered  about  the 
ward  and  garden  the  rest;  she  was  kept  on  "broth  diet."* 

The  amount  of  urine  and  of  its  chief  constituents  excreted  by 
her  on  all  the  days  when  circumstances  allowed  it  to  be  all  col- 
lected is  shown  in  this  table. 

Table  C. 


Date. 

Quantity  in 

cubic 
centimetres. 

Specific 
gravity. 

Urea  in 
grammes. 

Chloride  of 

sodium 
in  grammes. 

Sulphuric 

acid 

in  grammes. 

Phosphoric 

acid 
in  grammes. 

Aug.  17 

252 

1-018 

5-915 

1-389 

? 

•409 

"      19 

880 

1-006 

12-729 

4-400 

? 

•396 

"     20 

240 

1-014 

4-529 

2-040 

? 

None 

"     21 

270 

1-007 

3-429 

-337 

•206 

•061 

"     22 

360 

1-011 

5-.280 

2-340 

-212 

A  trace 

"     23 

1,000 

1-007 

15-353 

3-500 

•878 

-540 

"     24 

1,280 

1-007 

14-504 

4-480 

•715 

A  trace 

"     27 

570 

1-008 

9-405 

1-425 

-436 

A  trace 

"      28 

1,030 

1-007 

10-979 

3-862 

•596 

•494 

"     29 

730 

1-010 

9-252 

3-285 

•423 

A  trace 

"     30 

1,320 

1-008 

13-645 

5-120 

1-039 

? 

Sept.     1 

"        2 
"       3 

1,650 

1-008 

22-027 

1-358 

7-425 

"?"' 

"        4 
"        5 

900 

1-010 

13-231 

2-925 

•790 

•162 

It  will  be  noticed  that  in  the  last  three  observations  there  is 
an  improvement  in  the  amount  of  those  solid  constituents  of  the 
urine  which  are  an  evidence  of  the  force  of  vital  metamorphosis. 
This  improvement  was  coincident  with  the  addition  of  three 
ounces  of  brandy  to  her  diet  card,  an  ounce  and  a  half  at  din- 
ner, and  an  ounce  and  a  half  at  supper  daily. 

In  this  case,  then,  we  again  find  alcohol  appearing  to  aid  the 


*  Tea,  2  pints,  with  3  oz.  of  milk,  and  sugar  q.  s. ;  Bread,  12  oz. ;  Butter,  f 
of  an  oz. ;  Broth,  1  pint,  with  4  oz.  of  boiled  meat;  Gruel,  1  pint. 


602 


ON  ALCOHOL. 


vital  force  of  metamorphosis  when  taken  with  food.  The  quan- 
tity of  urine,  of  solid  matter  in  it,  of  urea,  of  chloride  of  sodium, 
and  of  sulphuric  acid,  is  augmented.  The  phosphates,  truly,  are 
remarkahly  deficient,  but  that  probably  dejiends  on  the  arrest  to 
the  renewal  of  brain  substance  which  the  injury  to  her  brain  en- 
tailed. 

Test  III. — The  first  subject,  W.  M.,  at  another  time  tried  the 
effect  of  alcohol  taken  in  another  way,  namely,  in  small  divided 
doses.  Six  ounces  of  brandy  were  drunk  daily  in  drams  of  half 
an  ounce  every  hour  from  9  a.m.  to  9  p.m. 

This  is  a  record  of  the  results : 


Table  D. 


Date. 

Quantity 
in  cubic 

centi- 
metres. 

Specific 
gravity. 

Urea  in 
grammes. 

Chloride 

of  Sodium 

in  grammes. 

Sulphuric 

acid  in 
grammes. 

Phospho- 
ric acid  in 
grammes. 

Uric  acid 

in 
grammes. 

Aug.  18 

1,520 

1-013 

30-465 

5-320 

2-210 

1-299 

•008 

"      20 

910 

1-025 

33-0'(7 

,     6-370 

2-375 

1-474 

•259 

"      21 

1,070 

1-022 

32-945 

6687 

2-246 

1-637 

-193 

"      22 

1,000 

1-021 

23-735 

6750 

1-897 

1-440 

•135 

"      '^3 

1,310 

1-015 

25-097 

7-205 

1-649 

1-061 

•196 

"      24 

1,530 

1-021 

41-867 

9-945 

3-064 

2-203 

•390 

One  day  was  an  interval  in  the  experiment,  and  only  the  usual 
amount  of  daily  diet,  without  extra  alcohol,  was  taken,  when  the 
numbers  stand  as  follows: 

Table  E. 


Date. 


Aug.  19 


Quantity 
in  cubic 
centi- 
metres. 


920 


Specific 
gravity. 


1-026 


Urea  in 
grammes. 


35-88 


Chloride  of 
Sodium  in 
grammes. 


5-750 


Sulphuric  ,  Phospho-     Uric  acid 

acid  in     iric  acid  in!         in 
grammes,    grammes.  '  grammes. 


2-374 


1-904 


-281 


It  is  very  clear  from  these  observations  that  alcohol  taken  in 
the  dram-drinkers'  fashion,  namely,  in  small  divided  doses,  by 
no  means  increases  metamorphosis.  It  rather  tends  to  diminish 
it,  and  this  diminution  is  not  sudden  or  immediate,  but  is  more 
and  more  for  a  certain  period,  till  the  retention  reaches  a  point 
at  which  a  critical  discharge  takes   place   in  healthy  persons. 


ON  ALCOHOL. 


603 


This  discharge  may  take  place  eitlier  in  consequence  of  the 
alcohol  being  left  off,  as  may  be  observed  in  the  day  of  interval; 
or  from  an  idiopathic  reaction,  as  on  the  24th  of  August.  This 
idiopathic  reaction  was  in  the  present  instance  doubtless  enhanced 
by  the  excitement  of  packing  up  for  a  short  visit  to  the  country 
which  began  on  the  next  day,  and  removed  the  subject  from  ob- 
servation. 

On  the  whole,  we  may  conclude  that  the  effect  of  continued 
small  doses  of  alcohol  is  to  diminish  vital  metamorphosis,  to  make 
it  irregidaj',  and  to  induce,  in  health^/  people,  the  necessity  for 
crises  of  evac2iation.  Its  first  actio7i  is  upon  the  stomach,  en- 
abling more  food  to  he  digested,  and  increasing  vitality ;  hut  if 
advantage  is  not  taken  of  this  first  action,  its  secondary  effect  is 
a  diminution  of  vital  functions  in  general,  and  of  digestion  among 
their  7iumher. 

Test  IV. — These  opinions  are  further  supported  by  the  fol- 
lowing set  of  experiments: 

T.  K.  C,  aged  forty-three,  healthy,  though  not  muscular,  of 
regular  life  and  habits,  took  daily  during  the  days  named  in  the 
table  a  quantity  of  food  proportioned  to  appetite,  viz.,  about  a 
pound  and  a  half  of  meat,  half  a  pound  of  bread,  a  pint  and  a 
half  of  tea,  with  milk,  sugar,  butter,  sauces,  &c.,  q.  s.,  half  a  pint 
of  water,  and  from  five  to  seven  glasses  of  port  or  sherry;*  care 
being  always  taken  not  to  annoy  the  temper,  and  so  nullify  the 
experiments,  by  overstrictness. 

Table  F. 


Quantity 
in  cubic 
centi- 
metres. 

Specific 
gravity. 

Urea  in 
grammes. 

Chloride 
of  sodium 

in 
grammes. 

Sulphuric 

acid  in 
grammes. 

Phospho- 
ric acid 
in 
grammes. 

Uric  acid 

in 
grammes. 

Amount  of  urine 
and  of  its  several 
parts  made  in  15 
days,  in   perfect 
liealth  and  usual 

diet 

Ditto  in  14  daysf 
Mean  daily  amo't 

18,800 
1,252 

15-337 
1-022 

493.852 
32-923 

137-655 
9-177 

26.487 
1-891 

27-683 
1-977 

3-839 

-274 

Which  may  be  reckoned  to  contain  from  33  to  35  per  cent,  of  proof  spirit, 
f  Of  one  day  the  record  was  imperfect,  the  sulphuric  acid,  phosphoric  acid, 
and  uric  acid  not  having  been  weighed. 


604 


ON  ALCOHOL. 


The  effect  of  taking  in  addition  at  times  between  meals  a  mode- 
rate amount  of  alcohol  in  divided  doses  is  shown  in  the  following 
table : — 


Table  G. 


Date. 

Quantity 
in  cubic 
centi- 
metres. 

Specific 
gravity. 

Urea  in 
grammes. 

Chloride 
ofsodium 

in 
grammes. 

Sulphuric 

acid  in 
grammes. 

Phospho- 
ric acid 
in 
grammes. 

Uric  acid 

in 
grammes 

Daily  quan- 
tity of  best 
French 
brandy  taken 
between 
meals. 

Nov.  16 
"  19 
"  22 
"     23 

Dec.  3 
«  5 
"  6 
"     17 

1,180 
1,800 
1,150 
980 
1,060 
1,320 
1,110 
1,180 

1-021 
1-013 
1-025 
1-025 
1-023 
1-019 
1-021 
1-020 

30-090 
28-854 
32-775 
27-930 
28-620 
30-875 
30-025 
30-208 

11-210 
9-900 

12-075 
9-310 
9-540 
9-900 
9-435 
9-440 

1-954 
1-906 

1-770 
1-800 

Trace 

•258 

3i}  fl.  ozs. 
8          " 
7*       " 
ll       " 

3  " 
8          " 
8          " 

4  " 

1-785 
1-865 
1-713 
1-586 

1-696 
1-980 
1-665 
1-652 

•339 
•330 
•299 
•343 

It  is  very  clear  from  these  figures  that  vital  metamorphosis, 
as  evidenced  by  the  amount  of  the  principal  solids  of  the  urine, 
is  diminished  by  thus  taking  more  alcohol  than  the  healthy  in- 
stinct prompts.  Not  only  are  the  whole  mean  amounts  low,  but 
on  no  day  do  they  come  up  to  the  average.  The  only  exceptions 
are  the  chloride  of  sodium,  which  is  slightly  increased,  by  what 
agency  I  cannot  tell,  and  the  uric  acid,  whose  augmentation  is, 
probably  with  justice,  considered  an  indication  of  an  approach- 
ing abnormal  state. 

It  may  be  remarked  that  a  greater  quantity  of  brandy  than 
that  recorded  above  spoilt  the  appetite  and  prevented  the  usual 
diet  being  taken  with  pleasure.  I  considered  that  this  would 
nullify  the  experiments  as  representing  the  effects  of  alcohol  in 
health,  for  it  placed  the  body  in  an  abnormal  state,  and  I  there- 
fore discontinued  them  for  a  time.^ 


I  have  often  given  you  at  the  bedside  reasons  for  administer- 
ing or  withholding  alcohol  in  special  cases;  but  I  have  been 
cautious  about  reducing  these  reasons  to  general  rules  without 
going  into  the  subject  more  fully  than  is  possible  in  the  wards. 

As  you  are  well  aware,  extreme  opinions  may  be,  and  have 


ON  ALCOHOL.  605 

been,  held  about  this  indubitably  powerful  re-agent,  Dr.  Brown 
(the  author  of  the  Brunonian  theory)  persuaded  himself  that  it 
was  a  panacea  for  all  human  ills,  and  a  direct  prolonger  of  life; 
but  by  dint  of  frequent  experimenting,  and  lecturing  with  a 
bottle  of  brandy  by  his  side,  he  soon  succeeded  in  giving  a  prac- 
tical refutation  to  his  own  words  by  ruining  his  health  and  short- 
ening his  existence.  Others,  again,  would  persuade  us  that  it 
is  a  pure  poison,  whose  degree  of  antagonism  to  life  is  in  a  direct 
ratio  to  the  quantity  used.  I  shall  take  for  granted  that  your 
experience  in  the  hospital  has  made  you  advocates  of  neither 
opinion;  but  that  you,  by  this  time,  have  seen,  or  seemed  to  see 
it  in  many  cases  saving  and  prolonging  life,  in  many  saving  and 
prolonging  health,  in  many  others  destroying  and  shortening 
both,  and,  again,  often  conceded  by  indulgent  doctors  as  an  in- 
nocent luxury  likely  to  do  neither  good  nor  harm. 

The  best  guide  to  the  effects  to  be  expected  from  a  re-agent 
on  a  diseased  body  is  the  intelligent  observation  of  its  effects  on 
a  healthy  body ;  and  I  think  that  alcohol  is  no  exception,  but 
that  a  knowledge  of  its  physiological  action  leads  directly  to  hs- 
therapeutical  application. 

The  experiments  of  Rudolf  Masing,  since  repeated  and  con- 
firmed by  MM.  Lallemand,  Perrin,  and  Duroy,  have  taught  us 
that  alcohol  passes  through  the  body  unaltered  in  chemical 
constitution,  and  does  not,  so  far  as  we  know,  leave  any  of  it» 
substance  behind.  It  remains  in  the  body  for  some  hours,  and 
during  that  time  exerts  an  influence  for  good  or  for  evil. 

It  is  not  strictly  an  "aliment;"  but  if  it  aids  the  appro- 
priation of  aliment,  it  may  be  looked  upon  as  an  "  accessory 
food"  in  health,  and  as  a  "  medicine  "  in  disease. 

What  is  the  nature  of  the  influence  which  it  exerts  ?  What 
is  its  action  upon  life  ?  It  is  usually  defined  as  a  "  stimulus  to 
the  nervous  system;"  and  so  long  as  "stimulus"  is  held  to 
mean  only  something  which  makes  one  feel  comfortable,  we  may 
be  satisfied  with  the  explanation ;  while  upon  the  nervous  sys- 
tem all  experimenters,  from  the  first  patriarch  downwards,  will 
agree  that  it  acts.  But  if  led  by  the  etymology  we  infer  that  it 
39 


606  ON  ALCOHOL. 

directly  augments  the  developed  force  of  the  nervous  functions, 
we  shall  fall  into  the  error  of  poor  Dr.  Brown. 

Let  us  be  a  little  more  particular  in  our  inquiries,  and  then 
I  do  not  think  we  shall  be  able  to  trace  any  direct  increase  of 
force  to  alcohol,  even  in  the  smallest  doses,  or  for  the  minutest 
periods  of  time.  The  sort  of  researches  of  which  those  detailed 
are  an  example,  show  pretty  clearly  that  its  continuous  use  [i.e. 
in  small  divided  doses)  does  not  add  power  to  vitality,  and  I 
think  we  shall  not  fail  to  come  to  the  same  conclusion  from 
observations  made  upon  its  more  immediate  effects. 

In  a  series  of  experiments,  conducted  with  another  object, 
Dr.  Edward  Smith  has  recorded  very  minutely  the  sensations 
experienced  after  brandy,  by  a  temperate  man,  with  a  fasting 
stomach.* 

What  are  the  first  effects  noticed  there  ?  Increased  life  ? 
Increased  function  ?  No — lessened  consciousness,  lessened  sen- 
sibility to  light,  to  sound,  and  to  touch. 

Then  there  comes  a  peculiar  sensation  of  stiffness  with  swell- 
ing of  the  skin,  which  is  noticed  particularly  in  the  upper  lip 
and  cheeks,  evidently  due  to  arrested  sensation  and  motion. 
These  are  very  unlike  spurs  to  extra  exertion. 

In  a  patient  lately  under  my  care  the  same  peculiar  sensation 
of  stiffness,  and  also  the  objective  phenomenon  of  rigidity  of  skin 
without  loss  of  sensation,  were  produced  by  the  pressure  of  dis- 
eased bone  on  the  fifth  nerve  inside  the  skull. f  If  we  call  this 
symptom  a  partial  paralysis  from  partial  obliteration  of  nervous 
function  (to  which  I  suppose  nobody  will  demur),  we  must  call 
the  effects  of  alcohol  also  a  partial  obliteration  of  nervous  func- 
tion, for  the  phenomena  are  strictly  identical. 

Dr.  Smith  further  records  among  the  "early  effects"  of  alco- 
hol, a  relaxation  of  the  dartos  and  other  muscles  connected  with 

*  "Transactions  of  Royal  Society,"  1859,  p.  732. 

f  In  this  lady  another  facial  characteristic  of  incipient  drunkenness  was 
simulated.  Ordinarily  the  affected  side  had  a  slight  diffused  fixed  color,  the 
other  being  pale  ;  but  when  she  blushed  the  healthy  cheek  was  colored  quickly 
and  deeply,  while  the  diseased  one  remained  unchanged  in  hue.  This  iS  the 
same  physical  phenomenon  which  is  exhibited  in  the  half-flushed  but  unabashed 
front  of  a  toper. 


ON  ALCOHOL.  607 

the  reproductive  system,  for  which  Ovid  elegantly,  and  Shakes- 
peare coarsely,  blame  the  later  and  more  obvious  influences  of 
drink.  The  sphincter  also  of  the  bladder  was  relaxed,  and 
to  this  the  observer  lays  the  increased  micturition  during 
indulgence. 

The  pulse  is  also  quickened.  At  first  blush  you  might  be 
disposed  to  view  this  as  an  indication  of  an  increase  of  nervous 
force.  But  do  not  be  hasty.  Observe  with  Dr.  Bedford  Brown* 
the  circulation  in  the  cerebrum  during  an  operation  on  the  skull, 
when  the  pulse  was  quickened  by  chloroform  ;  and  you  will  see 
the  heaving  and  bulging  of  the  brain  quieted,  the  surface  becom- 
ing pale,  and  the  hemorrhage  arrested.  The  quickening  of  the 
pulse  must  therefore  have  been  contemporaneous  with  diminished 
force  of  the  heart's  beat. 

Again,  observe  that  in  disease  those  patients  especially  ex- 
hibit the  phenomenon  of  quickened  pulse  whose  hearts  are 
most  enfeebled. 

It  would  appear  that  in  motion  of  a  purely  involuntary  cha- 
racter, quickness  indicates  diminution  of  force  and  not  increase. 

It  is  unnecessary  to  go  through  the  symptoms  of  advanced 
intoxication  by  alcohol :  all  observations  agree  in  showing  that 
large  doses  immediately  depress  the  nervous  centers,  and  that 
in  cases  of  absolute  poisoning  by  it  the  cause  of  death  is  cessa- 
tion of  the  muscular  respiratory  movements.  What  I  wish  par- 
ticularly to  remark  here  is,  that  the  primary  as  well  as  the 
secondary  action  is  a  diminution  of  vitality  in  the  nervous  sys- 
tem. 

Life  and  warmth  are  so  closely  connected  together  in  scien- 
tific as  well  as  in  popular  notions,  that  perhaps  the  most  striking 
evidence  of  diminished  vitality  is  the  lessened  capacity  to  gene- 
rate heat.  We  have  this  evidence  in  the  case  of  alcohol.  MM. 
Dumeril  and  Demarquay  published  in  1848  their  observation 
that  intoxicated  dogs  exhibited  a  great  loss  of  temperature,  and 
Dr.  Bdecker  and  Dr.  Hammond  find  in  their  own  persons  the 
same  result  from  even  moderate  doses  of  spirits.  This  accords 
with  and  explains  the  experience  of  Dr.  Rae,  that  alcoholic 
*  "American  Journal  of  the  Medical  Sciences,"  Oct.,  1860. 


608  ON  ALCOHOL. 

drinks  give  no  satisfaction  to  Arctic  voyagers,  and  of  Dr.  Hayes 
(Surgeon  and  Commander  in  U.  S.  second  Grinnell  Expedition), 
that  they  actually  lessen  the  power  of  resisting  cold.*  The 
"  warming  of  the  stomach  "  which  dram-drinkers  speak  of  with 
such  gusto  is  in  fact  a  fallacious  sensation  arising  out  of  insen- 
sibility to  external  influences.  I  think  we  may  without  hesita- 
tion conclude  that  alcohol  is  primarily  and  essentially  a  lessener 
of  the  power  of  the  nervous  system.  We  may  call  it  an  "anaes- 
thetic," if  it  is  allowed  us  to  extend  a  little  the  application  of 
the  term,  and  to  let  it  include  all  re^^gents  which  tend  to  in- 
terrupt the  connection  between  the  material  and  immaterial  of 
our  being,  between  force  and  visible  nerve,  whether  our  memories 
are  conscious  of  the  interruption  or  not.  It  is  only  when  it  is 
taken  in  considerable  doses  that  our  direct  feelings  note  the 
anaesthetic  action  of  alcohol.  Its  action  on  the  involuntary 
nervous  system,  more  important  in  a  physiological  point  of  view, 
is  anterior  to  that,  but  can  be  traced  only  by  inference. 

But  if  it  lessens  the  power  of  the  nervous  system,  it  may  be 
a.sked,  how  can  it  be  a  restorative?  How  can  that  which  lowers 
one  of  the  chief  manifestations  of  life  be  a  renewer  of  life? 

In  this  way; — first,  immediately, — by  blunting  the  nervous 
system  it  renders  less  rapid  the  influence  of  mind  over  it ;  and 
thus  all  external  agents  which  act  through  the  mind  on  the 
nervous  system  become  less  powerful  for  evil.  Resistance  is  in- 
creased: just  as  by  washing  a  burn  with  alcohol  or  nitrate  of 
silver  it  becomes  less  sensitive  and  less  fatal,  or  by  deadening 
sensation  with  ice  the  shock  of  an  operation  is  rendered  less 
dangerous  to  life. 

Secondly,  and  after  a  longer  period,  it  lowers  the  action  of 
the  nervous  system  on  destructive  metamorphosis,  and  thus  saves 
the  substance  of  the  body.  We  know  that  the  exercise  of  nerv- 
ous functions,  bodily  or  mental,  increases  destructive  metamor- 
phosis. We  know  too  that  when  either  bodily  or  mental  action 
is  in  excess,  there  is  an  arrest  of  the  constructive  appropriation 
of  food  by  the  stomach.  Our  own  personal  experience,  without 
the  aid  of  Shakespeare,  teaches  us  that  passion  and  emotion  as 

*  "  American  Journal  of  Medical  yciences,"  1859,  p.  117. 


ON  ALCOHOL.  609 

well  as  over-strained  muscular  labor  spoil  our  breakfasts  and  put 
a  stop  to  digestion.  Well  then,  anything  which  either  sensibly 
or  insensibly  interposes  between  this  sensible  or  insensible  nerv- 
ous action  and  the  digestive  viscera  must  tend  to  restore  that 
balance  of  the  two  in  which  healthy  life  consists.  Thus  Dr. 
Hammond,  having  placed  himself  on  an  insufficient  allowance  of 
food,  found  his  mental  and  bodily  powers  deficient — the  balance 
was  overthrown.  He  afterwards  took  a  small  quantity  of  alcohol 
with  each  meal,  and  then,  without  any  increase  of  diet,  he  gained 
weight  of  body,  and  his  mind  was  more  vigorous.  On  the  other 
hand,  if  he  added  alcohol  to  a  full  diet,  the  blunting  of  the 
mental  powers  was  very  perceptible,  and  there  was  feverishness 
of  body.  We  cannot  doubt  that  the  essential  action  of  the  alcohol 
was  identical  in  both  cases,  but  in  the  first  the  blunting  of  the 
nerve  force  was  requisite  for  perfect  life,  in  the  second  it  was 
not  wanted  and  was  therefore  injurious. 

Thus  do  I  interpret  the  effects  of  alcohol.  And  taking  this 
interpretation  as  a  basis,  I  would  deduce  therefrom  the  following 
clinical  rules  for  its  administration: 

I.  Give  alcohol  whenever  you  find  the  nervous  system  is  ex- 
hausting itself  and  the  body  by  an  activity  in  excess  of  the  other 
bodily  functions. 

Examples; — 

1.  In  delirious  fever,  especially  in  typh-fever.  Here  the  high 
specific  gravity  of  the  urine  is  a  warrant  to  you  of  the  great 
amount  of  destructive  metamorphosis  going  on,  and  the  failing 
strength  show^s  how  low  the  constructive  life  is.  Continue  the 
alcohol  as  long  as  the  tongue  is  dry,  and  the  mind  raves  instead 
of  sleeping,  and  the  hands  tremble. 

2.  In  pneumonia,  in  surgical  injuries,  in  erysipelas,  kc,  under 
the  same  regulations.  Here,  however,  our  path  is  not  so  clear 
nor  so  well  enlightened  by  physiology;  we  must  feel  our  way 
by  actual  observation  of  the  effects  produced  on  the  patient 
under  our  eye. 

3.  The  power  of  resistance  to  so.ne  poisons,  such  as  malaria, 
seems  increased  by  alcohol.  Thus  aguish  and  neuralgic  cases 
in  their  Protean  forms  bear  well  and  are  benefited  by  it  in  very 


610  ON  ALCOHOL. 

considerable  quantities.  Strangely  enough,  these  patients  on 
recovery  most  generally  take  a  dislike  to  fermented  or  spirituous 
drinks,  and  of  their  own  accord  leave  off  the  habit  of  taking 
them.  So  that  we  need  not  fear  that  we  shall  make  them 
tipplers  by  administering  the  remedy  during  their  illness. 

4.  After  violent  shocks  produced  by  mental  emotion,  or  ex- 
treme bodily  labor.  It  may  be  doubted  whether  the  prejudice 
felt  against  serving  out  spirits  to  soldiers  or  sailors  before  a 
battle  is  justifiable  ;  the  courage  or  apparent  strength  given  may 
be  tinsel,  but  the  power  of  resistance  to  wounds,  mental  and 
bodily,  is  something  real. 

5.  Where  the  patient  has  been  accustomed  to  excess.  It  will 
not  do  to  let  the  body  have  to  endure  the  natural  reaction  and 
the  disease  at  the  same  time.  The  reaction  must  be  postponed 
to  a  more  convenient  opportunity,  when  the  body  is  ready 
for  it. 

II.  Give  alcohol,  increase  the  dose  and  leave  it  off  under  the 
guidance  of  the  appetite  for  food.  As  long  as  a  sick  person 
takes  and  digests  food  better  with  alcohol  than  without,  so  long 
it  is  doing  good.  Beyond  that  point  we  have  no  evidence  of 
benefit  derived  from  it. 

III.  When  the  marked  feature  of  the  disease  consists  in 
retention  of  effete  matters  which  ought  to  be  discharged,  abstain 
from  the  use  of  alcohol  altogether. 

Examples: — 

1.  In  Uraemia  I  have  always  found  any  effects  which  could 
be  traced  to  alcohol  to  be  of  an  injurious  character;  under  its 
employment  the  giddiness,  the  blunted  intellect,  the  faintings, 
and  the  tendency  to  coma,  all  increase;  at  the  same  time  the 
urine  sometimes  becomes  more  scanty,  always  of  lighter  specific 
gravity;  and  I  cannot  say  that  even  the  dropsy,  for  which  the 
alcohol  is  most  usually  administered,  is  often  benefited. 

2.  Jaundice  seems  to  be  aggravated  by  alcohol. 

3.  The  uric  acid  diathesis  also  presents  an  objection  to  the 
use  of  alcohol ;  but  there  are  exceptional  complicated  cases  which 
appear  to  receive  benefit  from  occasional  doses. 

IV.  Divide  the  daily  allowance  into  two  or  three  doses  only, 


ON  ALCOHOL.  611 

giving  enough  at  once  to  produce  a  decided  effect.  The  action 
of  frequent  small  divided  drams  is  illustrated  by  the  experi- 
ments I  have  detailed — it  is  to  produce  the  greatest  amount  of 
harm  of  which  the  alcohol  is  capable,  combined  with  the  least 
amount  of  good. 

In  fever  I  usually  order  three  doses  a  day,  and  find  even  that 
division  not  always  advisable,  and  that  the  patients  do  better 
with  two  larger  doses. 

The  habitual  effect  of  small  wholesome  doses  is  to  blunt  the 
sensibility  to  the  slight  half  felt  corporeal  pains  which  daily 
life  begets.  It  removes  the  chains  of  the  corruptible  body  from 
the  soul.  Hence  a  freedom  and  brightening  of  the  intellect. 
But  it  is  only  the  moderate  man  that  can  enjoy  this  luxury ;  the 
attempt  to  drown  a  care  too  tall  for  a  shallow  bowl,  or  to  soothe 
a  pain  too  sharp  to  be  forgotten,  induces  an  excess.  Then  the 
scale  is  inclined  too  much  the  other  way ;  the  influence  of  the 
nervous  system  on  the  body  is  over-blunted,  and  the  just  degree 
of  its  action  requisite  to  perfect  health  is  missed. 

In  truth  this  balance  is  not  easy  to  adjust.  And  therefore  it 
is  lucky  for  us  that  alcohol  passes  so  freely  out  of  the  body  as 
Dr.  Percy,  Mr.  Masing,  and  the  French  physiologists  who  have 
repeated  their  experiments  have  shown  to  be  the  case.  It  is 
lucky  for  us  also  that  any  slight  harm  it  may  have  done  during 
its  sojourn  is  set  right  by  a  reaction  of  increased  metamorphosis 
or  evacuation,  of  which  an  example  has  been  given  in  the  ex- 
periments detailed  at  the  beginning  of  this  lecture. 


The  shape  in  which  alcohol  is  administered  is  in  many  cases 
not  a  matter  of  choice.  The  mighty  force  of  the  purse-strings 
often  restricts  us  to  the  coarsest  compounds.  New  whiskey  and 
gin  and  British  brandy  are  better  than  nothing,  but  let  us  not 
forget  that  they  contain  a  very  hurtful,  nay  almost  poisonous 
ingredient,  foozel  oil,  which  is  abundant  in  direct  proportion 
to  the  youth  and  low  price  of  the  article.  Age  changes  this 
into  more  wholesome  as  well  as  more  agreeable  ethers.  Any  of 
the  full-bodied  wines  are   better  for  acute  cases  than   spirits. 


612  ON  ALCOHOL. 

Port  perhaps  exhibits  in  its  commoner  varieties  more  of  the 
good  qualities  that  a  wine  shouhl  have  than  the  produce  of 
other  grapes.  I  mean  to  saj  that  second  and  third-rate  port, 
or  even  sham  port,  is  a  wholesomer  beverage  than  second  and 
third-rate  and  sham  articles  with  other  names.  But  if  the 
expense  is  no  object,  thoroughly  good  champagne  exhilarates 
more,  is  easier  digested,  and  does  the  good  without  the  harm 
better  than  any  of  its  rivals.  Of  course  a  high  price  must  be 
paid  for  a  genuine  article  in  the  instance  of  a  wine  so  restricted 
in  quantity.  The  use  of  beer  should  be  confined  to  those  cases 
where  we  wish  to  give  a  tonic  food  at  the  same  time  with  alcohol, 
and  also  where  the  powers  of  the  stomach  are  sufficient  not  to 
be  upset  by  a  slight  fermentation  of  the  sugar  which  always 
takes  place.  In  respect  of  its  chronic  effects,  it  seems  to  me 
that  a  long-continued  course  of  excess  in  beer,  even  moderate 
excess,  is  more  productive  of  degeneration  than  excess  in  wine 
or  spirits. 


LECTURE   LI. 
ON  BLOODLETTING. 

Part  1. —  The  power  of  renetval  in  the  animal  body  exemplified 
hy  the  quick  restoration  of  normal  blood  in  an  ansemic  girl — 
Application  of  these  facts  to  the  artificial  amnmia  induced  by 
bloodletting — Tlie  necessary  conditions  for  the  repair  of 
anaemia — Starving  and  bleeding  at  the  same  time  bad  practice 
— Reasons  for  bleeding — Fallacies  of  the  ancients. 

Part  II. — Cases  in  which  loss  of  blood  is  beneficial — In  some 
cases  of  apoplexy — In  pneumonia — In  the  congestions  of  typh- 
fever — In  serous  inflammations,  in  pleurisy,  pericarditis,  and 
peritonitis — In  renal  congestion  and  hsematuria — In  paralysis 
of  the  circulating  organs  from  over  distention — In  chronic 
diseases  of  the  shin — Conclusion. 

[Clinical,  St.  Mary's,  November  2,  1861.) 

A  Fortnight  ago  I  lectured  about  an  anaemic  patient  who 
had  been  in  the  hospital  a  couple  of  weeks.*  She  was  then 
already  showing  a  title  to  be  no  longer  so  called ;  and  now  she 
most  certainly  may  claim  exemption,  having  fairly  won  our  faith 
in  the  statement  that  her  natural  hue  is  rosy.  She  is  leaving 
London  to-day  with  enough  haematine  to  color  the  blood  through- 
out her  body  very  sufficiently. 

Let  us  take  stock  of  what  we  may  learn  from  her  agreeable 
change  of  looks. 

What  amount  of  manufacturing  industry  does  this  new  store 

of  haematine  prove  ?     Let  us  do  a  sum.     She  weighs  8  stone,  or 

1792  ounces :  of  this  weight  f  ths,  or  512  ounces,  is  blood  ;  and 

of  this  blood  -^^%%,  or  60  ounces,  should  be  red  disks.     Now  the 

See  previous  lecture  on  Anaemia.     Lecture  XXVII,  p.  353. 


614  ON  BLOODLETTING. 

careful  analyses  of  MM.  Andral  and  Gavarret  show  that  in  cases 
of  anoemia  of  a  marked  character  (as  this  was),  we  may  expect 
at  least  three-quarters  of  the  hsematine  to  be  wanting ;  so 
that  when  she  came  into  our  wards  it  may  be  fairly  taken  for 
granted  that  she  did  not  possess  above  15  ounces  ;  by  this  time 
I  think  with  equal  fairness  her  stock  may  be  considered  to  have 
got  up  to  45  ounces,  which  is  to  allow  that  she  still  wants  a 
quarter  of  her  perfect  health.  I  make  the  calculation  from 
observing  through  her  transparent  skin  how  healthily  red  the 
blood  has  grown.  By  this  reckoning  she  must  have  made  20 
ounces  of  blood-disks, — so  much  of  the  most  important  organic 
constituent  of  upwards  of  150  ounces  of  blood, — in  a  month  ! 

Mark  the  vigor  of  renewal  with  which  the  human  body  is 
dowered.  Learn  from  this  to  have  faith  in  its  power,  and  to 
trust  in  it,  though  prospects  may  look  untoward.  Learn 
especially  the  curability  of  even  fhe  most  unfavorable  specimen 
of  anaemia.  AndJ  learn  too  not  only  its  curability  when  it  is  a 
disease  which  has  come  of  its  own  accord,  but  also  the  facility 
of  repairing  artificial  loss  of  blood  when  it  is  employed  as  a 
remedy. 

I  hope  you  all  by  this  time  clearly  understand  that  physio- 
logically speaking  all  departures  from  full  health  are  diseases. 
The  artificial  states  which  many  of  our  remedies  produce,  some- 
times even  as  a  means  of  doing  the  patient  good,  but  more  often 
as  an  incident  unavoidable  and  lamented  by  us,  are  as  much 
diseases  as  any  of  those  on  the  roll  of  the  Registrar-General. 
Diarrhoea  is  as  much  diarrhoea,  whether  it  is  caused  by  epsom- 
salts,  by  a  felonious  poisoner,  or  by  a  poisonous  malaria.  So 
ansemia  is  as  much  anaemia  when  it  follows  our  lancet  and  our 
leeches,  a  swhen  it  arises  we  cannot  tell  how,  and  brings  a  patient 
to  us  for  advice.  It  must  be  equally  thought  of,  guarded  against, 
and  cured,  in  one  case  as  the  other.  But  what  I  particularly 
wish  to  insist  on  here  is  that  it  is  as  easily  thought  of,  guarded 
against,  and  cured  in  the  one  case  as  in  the  other. 

It  has  been  the  fashion  lately  among  certain  declaimers  to 
paint  the  physician  who  draws  blood  from  the  arm,  or  cups  or 
leeches  a  sick  man,  as  a  sanguinary  villian,  who  necessarily,  ex 


ON  BLOODLETTING.  615 

vi  termini^  takes  away  "  the  life,"  or  that  which  he  cannot  re- 
place. Not  only  novelists,  pill-dealers,  and  quacks  have  raised 
this  outcry,  but  it  has  been  joined  in  by  some  whose  knowledge 
of  physiology  ought  to  have  taught  them  the  fallacy  of  the 
popular  notion  and  the  argument  by  which  to  refute  it.  You 
will  clearly  perceive  from  the  calculations  through  which  I  have 
taken  you  that  by  proper  management  no  loss  is  easier  repaired; 
and  consequently  that  if  it  only  saves  a  patient  two  or  three 
nights'  sleeplessness  and  pain,  the  price  of  a  venesection  is  well 
paid  ;  and  still  more,  if  it  contributes  in  the  remotest  degree  to 
free  him  from  danger,  it  is  blood  well  spent. 

Nevertheless,  note  this,  that  if  the  loss  is  to  be  repaired,  the 
means  of  repair  must  he  given.  When  I  bleed,  you  will  observe 
that  I  take  down  the  diet  card  and  suit  it  to  the  circumstances, 
being  very  careful  that  the  patient  has  the  power  to  reinvest  the 
capital  drawn  out.  I  supply  with  one  hand  what  I  am  taking 
away  with  the  other.  I  begin  to  try  and  cure  the  anaemia, 
which  I  feel  myself  called  upon  to  produce,  at  the  same  moment 
that  I  am  producing  it.  "  Blowing  hot  and  cold,"  you  will  say. 
Precisely  so — that  is  what  I  intend.  I  blow  cold  with  my  bleed- 
ing, not  for  the  sake  of  blowing  cold,  but  because  it  is  the  in- 
evitable result  of  the  remedy.  "Facere  necesse  est  sumptum, 
qui  qugerit  lucrum."  I  blow  cold  not  in  order  to  induce  anaemia, 
but  for  other  quite  different  purposes  which  I  think  are  worth 
the  cost.  And  I  blow  hot  to  make  up  as  well  as  I  can  for  the 
evil  I  am  going  to  do. 

I  am  sure  that  the  sad  effects  of  the  too  zealous  practice  of 
our  fathers,  which  with  justice  have  been  cast  in  the  teeth  of  the 
medical  profession,  were  due  quite  as  much  to  the  starvation  as 
to  the  bleeding.  I  have  a  most  lively  and  painful  recollection  of 
seeing,  when  I  Avas  a  student  in  Paris,  M.  Chomel  and  others 
treating  pneumonia.  I  could  not  at  first  understand  why  in 
France  so  much  more  marked  and  more  hurtful  eifects  were 
produced  by  venesection  than  in  England.  At  that  period  we 
had  at  home  ampler  opportunities  than  now  of  seeing  it  prac- 
ticed ;  but  I  never  had  witnessed  such  prostration  follow  at 
St.   George's  in  London  as  1  did  at  the  Hotel  Dieu  in   Paris. 


616  ON  BLOODLETTING. 

I  was  puzzled  for  a  week  or  so,  till  at  last  I  noticed  that  the 
order  for  ^'- saignee''  was  accompanied  by  '■'•diete  absolue.''  I 
almost  doubted  my  knowledge  of  French,  and  was  obliged  to 
ask  of  the  bystanders  before  I  could  believe  that  this  meant 
an  utter  deprivation  of  all  food!  Here  was  an  immediate  ex- 
planation of  the  seeming  superior  toughness  of  my  countrymen  ; 
for  never  in  our  worst  days  did  we  carry  the  Sangrado  practice 
so  far  as  that.  Our  teachers  did  not  give  food  enough,  but 
they  never  bade  it  to  be  willfully  kept  beyond  their  patients' 
reach. 

The  bad  practice  of  starving  and  bleeding  at  the  same  time, 
took  its  rise  from  the  erroneous  doctrine  of  antagonism.  Ac- 
cording to  this  theory  disease  is  a  personal  enemy  to  be  over- 
come— A  Disease  with  a  proper  name  and  a  capital  letter  to  it, 
like  a  living  concrete  creature — a  something  to  be  combated  by 
a  something  which  is  as  opposite  to  it  as  possible.  Bleeding 
was  found  by  experience  to  be  useful  in  certain  morbid  states ;  it 
was,  therefore,  held  to  be  useful  in  virtue  of  possessing  qualities 
opposite  to  these  morbid  states.  Anaemia  and  depression  of  life 
are  the  most  constant  effects  of  bleeding;  therefore  anaemia  and 
depression,  it  was  argued,  are  the  benefactors  to  be  sought  for, 
and  whatever  aids  bloodletting  in  producing  anaemia  and  de- 
pression is  a  good  companion  to  it.  Of  course  starvation  was 
the  first  agent  thought  of,  adopted  in  all  its  integrity  by  the 
logical  French,  and  with  more  hesitation  by  our  countrymen, 
who  fortunately  do  not  carry  out  all  arguments  to  their  apparent 
conclusion,  and  therefore  are  often  right  without  knowing  why. 
The  abuse  has  brought  about  a  reaction ;  and  that  treatment 
which  was  considered  at  one  time  so  sovereign  that  its  gravest 
faults  were  viewed  as  virtues,  now  runs  a  risk  of  being  denied 
all  virtue  because  of  faults  capable  of  being  compensated  for. 

Against  this  I  feel  bound  to  raise  my  voice.  It  is  time  now 
to  have  done  with  the  reactions  for  and  against  letting  blood, 
which  has  been  going  on  throughout  the  period  of  the  Christian 
era;*  the  wave,  which  has  swelled  backwards  and  forwards  to  a 

*  A  short  sketch  of  the  reaction  in  favor  of  bloodletting  started  by  Galen,  is 
given  hy  the  author  in  the  "  Medico-Chirurgical  Quarterly  Review"  for  Octoben 


ON  BLOODLETTING.  617 

dangerous  height,  ought  to  settle  down  into  a  steady  stream. 
We  ought  to  know  clearly  why  we  bleed,  and  then  we  shall 
know  when  to  bleed. 

The  question  seems  to  me  one  proper  to  be  answered  by 
hydrostatics  rather  than  by  physiology.  The  most  important 
early  effect  of  external  injurious  action  on  the  tissues  is  that  the 
blood-vessels  lose  their  tone  and  become  dilated,  or  what  is 
called  the  "congestive  stage  of  inflammation"  occurs.  At  this 
conjuncture  the  more  pressure  of  fluid  there  is  inside,  the  more 
will  their  elasticity  be  impeded,  and  the  more  dilated  must  they 
become.  Taking  blood  from  them  is  like  emptying  the  urinary 
bladder  with  a  catheter  when  it  is  paralyzed  by  the  pressure  of 
its  retained  contents;  and  the  more  locally  the  remedy  can  be 
applied,  the  more  like  it  is  to  that  generally  approved  surgical 
operation.  Dropping  the  burden  which  weighs  down  their  life, 
the  vessels  are  enabled  to  go  again  to  their  work  of  regulating 
the  stream  of  the  circulation  by  their  elastic  coats.  So  far, 
then,  the  treatment  is  directly  restorative  and  reconstructive. 
Bloodletting  from  this  point  of  view  is  a  cure  of  local  congestion, 
and  to  the  local  symptoms  accordingly  it  may  be  expected  to  be 
beneficial. 

The  fault  of  our  forefathers  was  that  they  went  beyond  this. 
They  pictured  to  their  fancy  a  condition  of  universal  plethora, 
or  general  excess  in  quantity  of  blood  throughout  the  blood- 
vessels— a  condition  which  every  observant  and  practical  physi- 
cian now  knows  to  have  no  existence  in  nature.  Where  experi- 
mentally they  saw  good  results  follow  the  emptying  of  the 
blood-vessels,  they  pronounced  the  special  disease  before  them 

1858.  The  shrewd  chatty  Greek  hits  hard  at  his  opponents,  and  seems  to  have 
had  a  single  handed  fight  with  all  the  world  of  fashion  against  him,  and  yet 
came  out  victorious  in  the  end.  It  is  satisfactory  to  find  him  free  from  the  vul- 
gar notion  that  human  nature  and  its  diseases  are  liable  to  changes  of  type ;  he 
never  suggests  that  any  one  generation  could  stand  bleeding  either  betier  or 
worse  than  their  ancestors ;  but  he  notices  a  fact  which  probably  explains  a 
good  many  of  the  revolutions  of  public  opinion,  namely,  that  some  races  are 
much  more  affected  by  it  than  others — the  Keltic,  for  example,  more  than  the 
Latin.  It  would  be  interesting  to  trace  historically  how  the  prominence  of  one 
or  other  nationality  as  teachers  of  medicine  has  altered  the  prevailing  practice. 


618  ON  BLOODLETTING. 

to  be  a  proof  of  this  plethora,  and  hence  inferred  that  the  loss 
of  blood  was  directly  beneficial  to  the  system  at  large  by  re- 
straining an  excess  or  ''violence  of  life." 

We  know  now  that  a  destructive  agency  keeps  step  with  the 
reconstructive  one — that  our  gain  entails  a  loss.  By  blood- 
letting is  brought  about,  temporarily  or  permanently,  first  a 
decrease  in  those  red  blood-disks  which  are  the  characteristic  of 
health,  and  then  an  increased  proportion  of  fibrin  which  marks 
disease.  So  that  an  injury  is  done  to  the  mass  of  the  body  for 
the  sake  of  a  part — a  temporary  injury  for  the  sake  of  a  per- 
manent benefit. 

The  questions,  then,  which  we  have  to  decide  in  each  several 
case  are — first,  whether  we  can  by  our  art  certainly  repair  the 
artificial  injury  of  loss  of  blood; — secondly,  whether  the  part  to 
be  relieved  is  of  sufiicient  importance  to  the  whole  to  justify  the 
sacrifice  of  the  blood; — and  thirdly,  what  is  the  least  amount  of 
sacrifice  that  will  be  of  use. 

As  to  the  first  question,  the  daily  occurring  evidence  of  such 
cases  as  those  of  which  one  has  formed  the  text  of  to-day's  lec- 
ture, is  surely  enough  to  give  us  faith  in  the  means  of  renewal 
at  our  command.  As  to  the  second  and  third,  more  details  are 
required  than  we  have  time  for  to-day,  and  I  must  wait  for  an- 
other opportunity  of  enlarging  upon  them. 


(Part  11.— Clinical,  St.  Mary  s,  March  5,  1864.) 

Conceding  that  certain  evils  attend  a  loss  of  blood,  while  cer- 
tain advantages  may  also  be  derived  from  it,  the  next  question 
that  arises  is,  when  does  the  prospect  of  advantage  overbalance 
the  risk  of  evil?  It  is  my  purpose  to-day  to  set  before  you  a 
list  of  certain  instances  in  which  it  appears  to  me  to  do  so. 

1.  In  some  cases  of  apoplexy. 

The  cause  of  apoplexy  is  a  mechanical  arrest  of  the  cerebral 
nervous  functions.     And  this  may  take  place  in  two  ways: 

1.  By  actual  destruction  of  the  nervous  tissue. 

2.  By  impeded  circulation  of  blood  through  the  brain. 


ON  BLOODLETTING.  G19 

To  an  inward  wound  of  the  nervous  tissue  causing  actual  de- 
struction, whether  it  take  place  by  violence,  by  the  pressure  of 
a  clot  of  blood  or  of  a  tumor,  or  by  the  more  usual  case  of  atro- 
phic softening,  bloodletting  can  afford  no  assistance.  Its  imme- 
diate effect  on  the  lesion  is  bad,  and  the  more  remote  effects 
worse. 

But  to  the  impeded  circulation  a  cure  may  be  surely  applied. 
When  from  the  filling  up  of  the  cerebral  veins  and  capillaries 
with  black,  effete,  and  useless  blood,  no  room  can  be  found  for 
the  arterial  quickener — when  life  is  stagnant,  so  to  speak,  from 
the  stagnation  of  its  river  of  supply — then  you  may  restore  the 
stream  by  the  rough  and  ready  means  of  giving  it  an  artificial 
outlet. 

When  the  lips  and  tongue  are  tinted  blue;  when  the  pulse  is 
filled  and  sluggish ;  when  the  heart,  either  from  chronic  lesion 
or  from  repletion,  has  hardly  room  to  strike  the  ribs;  then  you 
may  withdraw  blood  with  advantage,  for  you  may  relieve  the 
congestion  which  is  obstructing  the  sanguification  of  the  brain. 

When  the  lips  are  pale  or  of  a  natural  color;  when  the  pulse 
is  free  or  empty,  striking  the  finger  with  a  high  sharp  stroke ; 
when  the  heart  beats  freely,  even  if  it  should  murmur  in  your 
ear  that  its  valves  are  imperfect;  then  the  lancet  and  the  leech 
are  useless,  and  therefore  hazardous. 

These  are  indications  afforded  by  the  local  nature  of  the  part 
affected ;  those  derived  from  the  general  symptoms  are  less  posi- 
tive, but  I  will  try  to  get  something  out  of'  them. 

In  the  first  place  as  to  convulsions — these  may  arise  from 
congestion,  as  often  happens  in  the  apoplexy  from  drowning  or 
hanging,  and  are  not  by  any  means  a  certain  contraindication 
to  bloodletting,  as  is  sometimes  stated.  It  is  however  as  well 
not  to  bleed  during  the  paroxysms.  But  I  think  that  where  the 
convulsion  is  local,  where  it  occurs  in  one  or  two  limbs  otherwise 
paralyzed,  that  then  it  usually  arises  from  local  lesion  of  the 
nerve  substance,  and  is  an  argument  against  drawing  blood. 

When  the  apoplexy  has,  in  a  previously  healthy  person,  come 
on  gradually,  beginning  with  stupidity,  giddiness,  and  headache 
without  local  paralysis,  and  passing,  in  times  varying  from  an 


620  ON  BLOODLETTING. 

hour  to  a  day,  into  complete  loss  of  seftse  and  motion;  when  the 
sphincters  slowly  become  relaxed,  and  continue  so;  when  the 
patient  may  by  a  violent  effort  be  a  little  roused,  lapsing  again 
into  unconsciousness;  then  it  is  not  uncommon  to  find  the  symp- 
toms dependent  on  congestion  and  relievable  by  bleeding.  When 
it  has  come  on  suddenly,  a  local  paralysis  being  contemporane- 
ous with  or  preceding  the  clouding  over  of  the  mind ;  when  the 
sphincters  hold  their  own,  or  are  only  intermittent  in  relaxation ; 
when  the  senses  which  have  been  suddenly  lost  are  either  com- 
pletely lost,  or  completely  recovered;  then  you  are  wisely  to 
abstain,  for  you  probably  have  to  do  with  broken  nervous  tissue 

This  is  about  as  much  as  you  will  have  time  to  think  over  with 
your  patient  before  you. 

It  has  been  argued  by  Drs.  Munro,  Kellie,  Abercrombie,  and 
others,  that,  the  brain  being  inclosed  in  an  unyielding  case,  and 
thus  excluded  from  atmospheric  pressure,  the  quantity  of  blood 
in  it  cannot  vary,  and  therefore  that  detraction  of  blood  from 
the  whole  bulk  of  the  fluid  in  the  body  can  make  no  impression 
on  it.  But  certain  experiments  exhibited  by  Dr.  Burrows  before 
the  College  of  Physicians  have  shown  that  at  least  the  color  of 
the  brain  and  the  qualify  of  blood  in  its  veins  may  be  much  af- 
fected by  external  circumstances ;  and  that  is  the  point  in  ques- 
tion ;  it  is  the  mal-distribution  of  the  blood,  the  venosity  in  the 
brain,  that  we  want  to  restore  to  its  normal  condition.  And  to 
that  result  I  feel  sure  that  bleeding  may  temporarily  contribute 
in  the  special  cases  of  which  I  have  spoken. 

2.  In  some  cases  of  pneumonia. 

The  reason  for  bloodletting  in  pneumonia  is  shortly  stated 
by  the  late  President  of  the  College  of  Physicians,  when  he  says, 
"Although  pneumonia  is  not  cured  by  bloodletting,  and  may 
be  rendered  fatal  by  excess  of  it,  yet  a  moderate  loss  of  blood 
early  in  the  disease  has  sometimes  the  power  of  determining 
favorably  both  its  type  and  its  duration.'*  That  is  to  say,  that 
though  the  pneumonia  is  not  cured  by  the  bloodletting,  the 
patient  sometimes  is.  Observe  the  experiments  shown  us  in  the 
great  lecture-theater  of  nature.     You  see  that  often  great  relief 

*  Dr.  Mayo  in  "  British  Medical  Journal,"  May  6,  1863. 


ON  BLOODLETTING.  621 

is  experienced  when  blood  is  expectorated  in  the  early  stages  of 
the  disease,  that  the  inflammation  ceases  to  spread  over  the 
tissue  of  the  lung  as  soon  as  the  mucus  is  stained  with  red. 
Get  the  start  of  this  by  prevenient  bleeding  or  cupping  or 
leeches,  when  it  is  allowed  by  the  other  circumstances  on  which 
I  enlarge  in  lectures  on  special  cases  of  pneumonia.  It  will 
diminish  the  dyspnoea,  the  oppression  and  the  pain.  And  you 
will  be  quite  safe  as  long  as  you  will  bear  in  mind  that  you  are 
doing  a  certain  harm  at  the  same  time  as  a  certain  good,  and 
anticipate  the  harm  by  proper  nutrition,  and  sustaining  the 
strength  of  the  body. 

Observe  also  the  experiments  exhibited  by  nature  in  localizing 
the  bloodletting.  The  natural  relief  of  pulmonary  congestion 
is  haemoptysis,  that  is  the  emptying  of  the  vessels  of  the  lung. 
You  cannot,  however,  let  blood  from  the  bronchial  and  pulmonic 
vessels.  What  shall  you  do  then  ?  Why  make  the  nearest  ap- 
proach in  your  power  by  taking  it  from  the  exterior  of  the  chest- 
walls  through  cupping  glasses  or  leeches. 

3.  I71  the  typhous  congestive  ivjiammations  of  the  lungs  and 
bowels  taking  blood  by  leeches  or  cupping  from  the  nearest 
external  surface  is  good  practice.  The  relief  is  usually  very 
rapid  and  immediate,  and  the  risk  run  from  a  small  loss  of  blood 
very  little.  The  fluid  you  take  away,  though  called  by  the 
common  name  of  blood,  is  not  the  same  as  an  equal  quantity 
circulating  in  the  veins  of  a  healthy  man.  It  is  more  or  less 
useless  for  the  purposes  of  life,  and  the  loss  is  far  from  being  in 
a  direct  ratio  to  the  amount  taken.  It  is  more  important  that 
the  patient  should  regain  the  use  of  his  bowels,  or  of  a  congested 
lung,  than  that  he  should  keep  such  imperfect  stufi"  circulating 
or  stagnating  in  his  blood-vessels.  Of  this  I  have  spoken  at 
length  in  former  lectures. 

4.  The  same  remarks  will  apply  to  ae^lte  dysentery,  in.  which, 
indeed,  an  indication  of  treatment  is  aff"orded  by  the  natural 
course  itself  of  the  disease.  The  worst  cases  are  those  in  which 
there  is  no  loss  of  blood  by  stool,  and  alarming  as  it  is,  sangui- 
neous purging  often  saves  the  life  of  the  sick. 

5.  Li  inflammations  of  serous  membranes,  such  as  plc-urisy,  peri- 

40 


622  ON  BLOODLETTING. 

carditis,  and  peritonitis,  a  great  part  of  the  danger  arises  from 
the  quickness  with  which  the  continuous  parts  of  the  same  tis- 
sue yield  to  the  destructive  influences  of  neighborhood.  This 
quickness  is  certainly  checked  by  the  direct  counteraction  which 
loss  of  blood  affords  to  the  congestive  stage  of  inflammation. 
The  local  capillaries  show  their  partial  deficiency  of  life  in  loss 
of  elasticity,  in  dilatation,  and  in  being  overfilled  with  blood. 
Leech  the  neighborhood,  and  you  temporarily  empty  them,  and 
you  postpone,  at  least  for  a  time,  the  coming  inflammation.  You 
gain  time  ;  and  time  is  no  mean  gain,  for  it  gives  the  smitten 
body  a  period  of  rest  in  which  it  can  store  up  force  to  effect 
a  cure.  But  do  not  expect  too  much,  remember  it  is  only  time 
that  you  gain,  for  when  the  first  stage  of  inflammation  is  over, 
when  "its  work  is  done,  its  path  of  ruin  past,"  then  the  time 
for  taking  blood  is  gone  by,  and  your  detraction  of  it  is  a  rob- 
bery. 

As  to  locality,  the  nearer  you  can  approach  to  the  part 
inflamed  the  better ;  for  the  action  is  hydrostatic,  and  mechani- 
cal forces  lose  by  distance.  In  peritonitis  put  your  leeches 
on  the  painful  side  of  the  belly — that  is,  where  congestion  is 
going  on,  for  after  effusion  of  fibrin  or  pus,  pain  ceases  at  the 
point  of  effusion.  In  pericarditis,  apply  them  close  together 
at  the  level  of  the  mammae,  or  where  the  apex  of  the  heart 
beats,  according  to  where  the  chief  pain  on  pressure  is  found 
to  be.  In  women  with  full  bosoms,  shun  the  mammary  gland  ; 
not  because  you  will  hurt  it,  but  because  it  removes  your  leeches 
too  far  off.  In  pleurisy,  leech  as  near  the  pain  as  may  be ;  take 
care,  however,  to  keep  above  the  level  of  the  diaphragm  ;  even 
although  the  stitch,  as  often  happens  in  diaphragmatic  pleurisy, 
should  be  felt  by  misplaced  sensibility  below  the  ribs.  In  this 
case  especially  you  should  mark  for  the  nurse  the  spot  where 
the  leeches  are  to  be  put  on ;  for  you  must  remember  that  she 
is  not  an  anatomist,  and  has  not  learned  where  the  pleura  ends 
and  begins ;  she  is  likely,  therefore,  to  be  led  into  error  by  the 
faulty  sensations  of  the  patient. 

The  amount  of  bloodletting  must  be  proportioned  to  the  risk 
run  by  the  spread  of  the  inflammation.     In  peritonitis  this  is 


ON  BLOODLETTING.  623 

very  great  and  immediate :  leech,  therefore,  freely,  and  cover 
the  congested  spot  with  the  remedy.  Two  dozen  leeches  even 
are  not  too  many  in  pressing  cases.  Then  cover  the  place 
(having  first  stopped  up  the  bleeding  bites  with  dry  lint)  with  a 
linseed  poultice,  or  Markwick's  spongio-piline  ;  keep  the  patient 
quite  still,  and  procure  sleep  with  opium.  Thus  you  will  make 
the  best  use  of  the  time  gained. 

Follow  the  same  rules  in  pericarditis  ;  only  you  will  not  want 
so  many  leeches,  as  there  is  less  space  to  be  covered ;  six,  eight, 
or  at  most  ten,  will  be  quite  enough,  according  to  the  size  and 
sex  of  the  patient,  and  the  correspondent  size  of  the  exposed 
piece  of  pericardium.  In  pericarditis  you  are  more  likely  to 
require  a  second  and  a  third  application,  as  you  cannot  procure 
such  perfect  rest  to  the  heart  as  to  the  abdominal  viscera — an 
additional  reason  for  being  moderate  in  the  number  of  the  first 
lot.  Poultices  and  opium  are  as  well  spent  here  as  in  perito- 
nitis— do  not  spare  them. 

Pleurisy,  unaccompanied  by  pneumonia  or  catarrh,  is  not  such 
a  pressing  complaint.  Half  a  dozen  leeches  and  a  poultice  are 
usually  quite  enough  to  manage  it. 

6.  Congestioti  of  the  kidneys  is  apt  to  produce  a  continuous 
drain  of  blood  by  the  urine ;  and  from  the  great  weakness  thus 
arising,  it  seems  not  unlikely  that  the  material  thus  lost  is 
arterial  and  vitally  important.  Moreover,  protracted  congestion 
of  the  kidneys  often  ends  in  the  permanent  degeneration  of 
Bright's  disease — a  result  most  unhappy.  When,  therefore, 
after  scarlatina,  exposure  to  cold,  blows  or  other  causes,  I  find 
visible  hsematuria,  I  almost  always  cup  the  patient  on  the  loins. 
I  cannot  say  that  the  practice  is  invariably  successful  in  effecting 
its  inteniion  ;  for  the  loins  are  some  way  ofi"  the  kidneys,  and 
the  force  of  the  remedy  is  much  diluted  by  the  time  it  gets  to 
influence  the  point  of  attack.  But  it  succeeds  often  enough  in 
stopping  the  hasmaturia  to  make  it  worth  while  to  lose  eight  or 
ten  ounces  of  blood  in  the  trial. 

7.  The  same  considerations  may  sometimes  induce  us  to  treat 
by  emission  of  blood  a  congestion  unimportant  in  itself,  but 
important  from  its  neighborhood  ;  such  as  swelling  of  the  tongue 
or  tonsils,  which  we  fear  might  suddenly  compress  the  glottis. 


624  ON  BLOODLETTING. 

8.  When  the  heart  is  temporarily  paralyzed  by  over  distention, 
either  completely,  so  as  to  produce  apparent  death,  or  partially, 
so  as  to  produce  what  is  technically  known  as  a  "  very  oppressed 
pulse,"  joined  with  anxiety  and  dyspnoea,  then  bleeding  and 
still  more  cupping  the  cardiac  region  is  often  of  signal  service. 
The  relief  is  of  course  mechanical ;  the  dormant  excitability  of 
the  heart  is  roused  by  the  artificial  motion  communicated  to  the 
circulation  ;  and  perhaps  also  the  sensitiveness  of  the  nervous 
system  is  heightened  by  the  absence  of  blood,  just  as  tonic  mus- 
cular contractions  are  induced  by  excessive  hemorrhage,  by 
starvation,  &c.* 

9.  Bloodletting  may  sometimes  be  employed  in  chronic  skin 
diseases,  to  render  more  efficacious  the  action  of  certain  specific 
remedies  for  certain  specific  forms.  Thus  in  lepra,  and  psoriasis, 
I  have  several  times  arrived  at  a  point  at  which  arsenic  and 
sulphur  did  no  further  good,  even  in  doses  larger  than  are 
usually  considered  safe.  After  bleeding  the  patient,  a  smaller 
dose  produced  an  immediate  effect  and  a  rapid  renewal  of  healthy 
skin.  I  have  remarked  the  same  fact  in  a  nearly  equal  degree, 
as  respects  the  action  of  alkalies  in  eczema.  Last  week  I  called 
your  attention  in  the  admission-room  to  the  arms  and  legs  of  a 
gardener,  as  exhibiting  quite  a  typical  case  of  eczema  in  pic- 
turesque distinctness :  I  had  him  bled  to  six  ounces,  gave  him  a 
bran  bath  and  only  three  doses  of  liquor  potassse,  and  next  day 
when  we  saw  him  in  bed  he  was  so  much  better  that  I  was 
obliged  to  apologize  to  you  for  the  departure  of  most  of  the  char- 
acteristics of  the  disease.  And  last  year  in  a  case  of  extensive 
lichen  no  good  at  all  was  done  by  emollient  baths  of  bran  and 
linseed,  till  I  bled  the  patient,  and  then  these  simple  agents 
were  sufficient  to  effect  a  cure.  After  these  bleedings,  if  bene- 
ficial, no  weakness  is  felt. 


These  are  examples  of  the  principal  circumstances  under  which 
you  will  find  me  in  my  practice  think  it  advisable  to  take  blood. 

*  See  M.  Chossat's  observations,  quoted  in  Lect.  II,  pp.  33 — 40. 


ON  BLOODLETTING.  625 

You  will  see  that  they  generally  agree  in  this,  that  there  is  a 
want  of  due  circulation,  a  true  deficiency  in  that  important 
function  of  the  vascular  system.  The  flow  of  blood  restores  this 
circulation,  for  though  the  b\ood  flows  out  of,  instead  of  flowing 
through  the  vessels,  it  is  a  better  representation  of  the  living 
act  than  the  previous  stagnation.  In  all  the  concerns  of  organic 
life,  as  of  social  life,  anything  is  preferable  to  stagnation. 

The  physiological  reasons  for  localizing  as  far  as  possible  our 
bloodletting  are  exceedingly  well  put  by  Dr.  Young.  "  The 
effect  of  venesection  must  be  not  only  more  rapidly,  but  also 
more  powerfully  felt  in  a  neighboring  than  in  a  distant  part ; 
and  although  the  mean  or  permanent  tension  of  the  vessels  of  any 
part  must  be  the  same,  from  whatever  vein  the  blood  may  have 
been  drawn,  provided  that  they  undergo  no  local  alteration,  yet 
the  temporary  change,  produced  by  opening  a  vein  in  their 
neighborhood,  may  have  relieved  them  so  efi"ectually  from  an 
excess  of  pressure,  as  to  allow  them  to  recover  their  natural 
tone,  which  they  could  not  have  done  without  such  a  partial  ex- 
haustion of  the  neighboring  vessels."* 

The  history  of  opinions  on  the  subject  of  bloodletting  shows 
us  four  sects  or  parties,  each  one  of  which  has  at  various  times 
out-weighed  its  rivals  in  number  of  adherents.  First,  the  fol- 
lowers and  predecessors  (for  '•'' vixere  fortes  ante  Agamemnona") 
of  Hippocrates,  who  sometimes  bled,  but  always  fed,  their  pa- 
tients. Second,  the  disciples  of  Erasistratus,  who  denounced 
bleeding  as  robbery,  and  prescribed  in  its  place  a  complete  star- 
vation for  several  days — diarpiTOQ  hai-ia.  Third,  the  continental 
practitioners  of  the  last  two  centuries,  immortalized  but  not 
checkedf  by  the  satire  of  Moliere  and  Le  Sage,  who  both  bled 
and  starved  at  once.  Fourth,  the  followers  of  Brown,  who  re- 
place bleeding  by  alcohol. 

From  what  has  been  said  it  will  be  seen  that  I  should  find 

*  Croouian  Lectures  in  "Philosophical  Transactions  of  Royal  Society,''  1809. 

f  In  the  towns  of  Southern  Italy  and  Sicily  there  is  scarcely  a  single  public 
thoroughfare  which  does  not  exhibit  the  shop  of  a  Salassatore  or  bleeder,  whose 
handsome  fittings  and  brilliantly  painted  sign,  of  a  naked  man  spouting  blood 
from  arms  and  legs  at  once,  are  proofs  of  a  thriving  business. 


626  ON  BLOODLETTING. 

myself  a  member  of  the  first-named  sect,  if  the  unhappy  mania 
of  party  spirit  were  again  to  afflict  our  profession  as  it  has  done 
of  old.  And  were  hero-worship  again  to  become  one  of  our 
failings,  I  should  probably  select  as  the  Bible  of  my  medical 
faith  Hippocrates' "  Regimen  of  Acute  Diseases."  For  if  it  might 
be  allowed,  out  of  consideration  for  the  climatic  differences  be- 
tween Athens  and  London,  to  substitute  beef-tea  for  gruel,  there 
is  very  little  in  that  capital  course  of  lectures  which  does  not 
accord  with  the  daily  practice  of  those  I  think  wisest  among  us 
in  the  present  day. 

But  how  different  are  the  grounds  on  which  our  practice  is 
based  !  The  Greek  had  merely  the  limited  guidance  of  empirical 
observation,  aided  in  his  individual  instance  by  a  remarkably 
shrewd  instinctive  feeling  of  what  the  normal  progress  of  disease 
is,  and  how  far  it  is  modified  by  remedies.  We  have  a  crowd  of 
anatomical  and  physiological  facts,  which  may  be  brought  to 
bear  on  the  subject,  and  which  may  keep  us  from  wasting  our 
time  in  unfruitful  experiments ;  and  we  have  spread  open  before 
us  in  our  public  hospitals  a  wide  volume  for  those  who  will  read 
it  aright,  illustrating  the  natural  history  of  disease  and  its  con- 
sequences. It  is  not  necessary  for  any  one  of  us  to  be  an  Hip- 
pocrates for  us  to  cure  disease  much  more  safely  than  he  was 
able  to  do,  and  probably  in  no  remedy  is  this  so  clearly  shown 
as  in  the  application  of  bloodletting. 


LECTURE    LII. 

REVIEW  OF  OBJECTIONS   AGAINST  THE   THEORY   AND 
PRACTICE  OF  CURE  BY  RENEWAL  OF  LIFE. 

One  that  for  the  first  time  happens  to  hear  it  made  an  aphor- 
ism (as  it  has  been  in  the  preceding  lectures)  that  morbid  phe- 
nomena are  always  evidence  of  deficient  vitality,  may  not  un- 
reasonably find  a  stumbling-block  in  the  following  observations 
which  a  thoughtful  student  of  nature  will  not  fail  to  make  on  the 
patients  before  him  : 

First.  Morbid  excretions  and  secretions  are  often  more 
copious  than  natural. 

Second.  Morbid  solid  products  may  add  to  the  size  of  the 
parts  they  are  attached  to. 

Third.     Morbid  muscular  motions  may  be  excessive. 

Fourth.  Morbid  mental  phenomena  may  be  apparently  ex- 
cessive. 

Fifth,  Morbid  temperature  is  often  higher  than  the  normal 
average. 

Sixth.     Sensibility  is  sometimes  increased  by  disease. 

I  will  answer  these  objections  seriatim. 

First  objection. — The  copiousness  of  morbid  excreta  will  be 
observed  to  depend,  not  on  the  addition  to  them  of  such  organ- 
ized products  as  are  useful  in  assisting  vital  processes,  but  of 
such  as  are  the  result  of  the  physical  decomposition  of  the  body, 
or  of  its  deficient  resistance  to  external  cosmical  agents.  In 
diarrhoea  there  is  not  an  extra  formation  of  pepsine  or  other  di- 
gestive juices  in  the  alimentary  canal,  but  a  flood  of  liquid  re- 
sulting from  the  diminished  endosmosis  compared  with  exosmo- 
sis — just  as  you  have  a  flow  of  water  down  the  waste-pipe  of  a 
cistern  when  you  do  not  use  so  much  in  the  house  as  usual. 
Thus  also,  medicines  and  diseases  which  increase  the  amount  of 


628  KEVIEW. 

hepatic  secretion  found  in  the  stools,  do  so  by  poisoning  either 
the  secretion  itself  or  the  intestinal  absorbents  ;  so  that  not  the 
quantity  made  but  the  quantity  wasted  is  in  excess.  Waste  is 
no  proof  of  life.  Again,  in  urine  abnormally  augmented  there 
is  found  no  excess  of  its  essential  part,  urea,  but  in  almost  all 
cases  a  deficiency  ;  those  instances  of  apparent  excess  formerly 
classed  as  azoturia,  baruria,  &c.,  really  resolving  themselves  into 
irregular  retention  and  consequently  irregular  evacuation.  The 
urea  is  first  retained,  then  thrown  out  for  two  days  in  one." 
Again,  in  the  bronchi,  how  can  we  call  excessive  mucus  an  ex 
cess  of  life,  when  even  popular  observation  takes  its  superabun- 
dance (the  "death  rattle")  as  a  proof  of  imminent  death  ?  It  is 
not  the  business  of  healthy  mucous  membranes  to  be  covered 
with  mucus  at  all,  and  when  they  are  so  it  is  a  sign  of  deficient 
life,  local  or  general.  Mucous  globules  consist  of  young  epithe- 
lium, or  rather  of  matter  which  ought  to  have  been  epithelium, 
which  ought  to  have  lived  remaining  adherent  to  the  basement 
membrane,  and  performed  the  local  duties,  but  which  has  mis- 
carried and  become  a  tenacious  fluid  instead  of  a  continuous 
solid.* 

Second  objection,, — viz.  That  morbid  products  may  add  to 
the  size  of  the  parts  they  are  attached  to. 

The  fact  that  diseased  parts  are  often  increased  in  solid  bulk 
is  of  serious  import,  for  it  suggests  two  questions,  both  of  very 
practical  bearing  : 

Firstly,  does  augmented  bulk  imply  augmented  general  life  in 
the  individual  ? 

Secondly,  does  it  imply  augmented  local  life  in  the  part  af- 
fected ? 

To  the  first  question  a  suflScient  answer  may  be  found,  which 
a  few  visits  with  the  eyes  open  to  either  medical  or  surgical 
wards  of  a  hospital  may  show  to  be  true ;  namely,  that  it  is  not 
the  burly,  full-pulsed,  red-blooded  man  of  large  appetite  and 
great  muscular  power  that  is  most  liable  to  exhibit  a  specimen 
of  solid  morbid  matter,  but  the  ansemic  starveling,  quivering  at 
a  breeze  or  a  blow. 

*  See  Lectures  III,  IV,  V. 


REVIEW.  629 

In  what  corpse  do  you  find  the  largest  weight  of  fibrin  thrown 
out  in  the  peritoneum  in  the  shortest  possible  time  ?  In  one 
dead  of  puerperal  fever — that  is,  in  the  weaker  sex  at  the  period 
of  its  greatest  weakness. 

In  whom  is  rheumatic  fever  most  likely  to  cause  pericarditis, 
with  its  great  masses  of  morbid  matter  ?  In  the  young  over- 
grown persons,  especially  if  a  female,  and  more  especially  if  an 
over-worked,  under-nourished  needlewoman,  or  maid-of-all- 
work. 

In  whose  heart  do  the  adhesions  which  are  the  consequences 
of  this  pericarditis  most  readily  end  in  hypertrophy  ?  Not  in 
the  well-fed  and  well-clothed  idle  or  professional  man  or  woman; 
but  in  the  same  weakly  sex,  and  under  the  same  weakening  cir- 
cumstances as  induced  the  original  lesion. 

Cancers  and  other  tumors  again  are  found  most  often  and  of 
quickest  growth  in  the  least  lively  bodies,  in  the  least  lively 
parts,  and  in  those  which  are  half  killed  by  wounds,  injuries,  or 
previous  disease. 

It  is  perhaps  not  impossible  that,  while  the  general  vitality  of 
the  individual  is  lessened,  some  part  might  exhibit  an  extra 
amount.  But  morbid  processes  are  not  evidences  of  it ;  they 
rather  resemble  developments  of  a  lower  form  of  life  ;  their  pro- 
ducts, though  abundant,  are  less  vital  than  the  normal  growth 
whose  place  they  take ;  their  existence  is  temporary,  and  "they 
are  not  capable  of  becoming  permanent  constituents  of  the  body, 
or  of  lasting  as  long  as  the  individual."*  Examine  during  life 
a  patient  with  thickened  heart,  and  the  pulse  does  not  strike 
your  finger  vigorously,  the  apex  of  the  organ  does  not  beat ' 
sharply  against  the  ribs ;  indeed,  the  thicker  it  gets,  the  less 
powerful  is  both  pulse  and  beat,  and  the  less  actively  does  the 
blood  course  through  the  vessels.  Dissect  it  after  death,  and 
you  will  seldom  fail  to  find  a  pale  tissue  with  microscopical  evi- 
dences of  commencing  fatty  degeneration.  Still  more  evident 
is  the  same  degenerative  tendency  in  cancer.  The  tissue  of  ma- 
lignant tumors,  directly  it  ceases  to  grow  rapidly,  begins  to  de- 
cay, to  shrink,  and  to  be  converted  into  fat.     It  is  hard  to 

*  Virchow's  "  Cellular  Pathology,"  p.  456. 


630  REVIEW. 

imagine  local  strength  or  local  excess  of  life  producing  such  a 
weakling  crop. 

In  cancer,  truly,  there  is  a  continuous  reproduction  of  new 
foci  of  growth,  a  new  progeny  of  prolific  cells,  which  certainly 
does  look  like  an  extension  of  local  life  over  a  larger  space,  if 
not  the  production  of  fresh  local  life.  But  then  we  should  reflect 
that  the  highest  and  most  vital  function  of  nutrition  is  the  re- 
tention of  the  form  of  the  body  or  its  separate  parts;  that  in 
morbid  augmentations  of  size  this  is  lost :  the  controlling  power 
is  absent,  and  the  more  so  the  more  morbid  and  the  larger  the 
augmentation  is.  The  formlessness  of  cancerous  and  of  the  so- 
called  hypertrophic  tissues  seems  to  refer  them  to  a  lower  grade 
of  organic  life  than  normal. 

It  strikes  me  that  some  difficulty  has  arisen  from  a  common 
confusion  of  the  ideas  of  growth  and  life.  Life  is  manifested 
in  the  more  or  less  retention  of  the  typical  form  by  continuous 
metamorphosis  of  the  substance.  Destructive  metamorphosis  is 
just  as  much  a  necessary  part  of  this  as  constructive.  Life  in- 
cludes growth  and  controls  it,  and  they  cannot  be  identical,  or 
we  should  arrive  at  the  anomaly  of  calling  completed  tissue,  to 
which  nothing  requires  to  be  added,  "dead;"  a  misapplication 
of  terms  which  would  be  almost  as  difficult  to  reconcile  with 
common  usage  as  the  asserting  that  a  man  ceased  to  live  on  at- 
taining his  full  stature. 

Third  objection. — That  morbid  muscular  motions  are  often 
excessive. 

The  chief  function  of  muscular  tissue  is  to  contract,  and  there- 
fore when  it  contracts  oftenest  and  most  it  might  at  the  first 
blush  seem  to  be  the  fullest  of  life.  But  on  the  other  hand,  it 
ought  to  contract  in  obedience  to  antecedent  animal  acts ;  volun- 
tary fibers  in  obedience  to  the  will,  the  involuntary  in  obedience 
to  other  demands.  And  moreover  it  does  not  seem  certain  that 
relaxation  is  not  as  much  an  active  state  as  contraction,  for  reflex 
muscular  actions,  winking,  yawning,  sneezing,  laughing,  &c., 
can  often  be  prevented  by  a  voluntary  eff"ort  to  keep  the  muscles 
relaxed.  The  highest  development  of  life  is  the  fullest  submis- 
sion of  the  muscle  to  its  natural  master,  the  will. 


REVIEW.  631 

Observe,  in  excessive  hemorrhage,  Avhich  I  suppose  nobody 
calls  an  exaltation  of  vitality,  there  occur  spasm,  convulsion, 
sometimes  epilepsy.  In  a  state  universally  acknowledged  to  be 
one  of  weakness,  you  find  that  irregular  constant  motion  called 
subsultus  tendinwn,  and  the  nearer  death,  the  more  marked  it 
is.  When  the  limbs  are  wearied  out  by  violent  exercise,  they 
start  and  quiver,  and  cramps  keep  us  awake  after  a  hard  day's 
walking.  The  less  powerful  the  will,  the  more  frequent  and 
more  violent  are  hysteric  paroxysms.  In  short,  the  rule  appears 
to  be,  that  as  the  debility  is  greater,  the  more  uncontrollable  are 
the  muscular  contractions,  and  the  easier  are  they  excited. 

Fourth  objection. — That  morbid  mental  phenomena  may  be 
excessive.  If  we  examine  carefully  the  minds  of  those  in  whom 
one  or  other  mental  faculty  appears  excessive,  we  find  that  the 
apparent  excess  is  due  to  the  deficiency  of  some  other  faculty, 
which  in  the  normal  state  balanced- or  controlled  it.  Thus  for 
instance,  the  drawing  and  handwriting  of  incipient  lunatics  will 
exhibit  a  delicacy  and  minuteness  almost  supernatural.  This 
appears  to  arise  from  want  of  imagination  and  taste.  Again, 
the  wonderful  memory  for  little  things  which  idiots  exhibit  is 
seemingly  dependent  on  the  emptiness  of  their  minds  of  other 
sensations.  That  intellect,  judgment,  poetic  or  artistic  power 
are  ever  really  developed  by  insanity,  is  merely  a  popular  de- 
lusion. 

Fifth  objection. — Life  and  warmth  are  so  wedded  together  in 
men's  fancy,  that  the  heightened  temperature  in  inflammation 
and  fever  has  contributed  more  than  anything  else  perhaps  to 
beget  the  idea  of  the  phenomena  of  disease  being  due  to  excess 
of  vital  action. 

It  is  true  that  the  heat  of  the  body  is  greater  in  fever;  but 
that  is  no  proof  that  more  is  elicited,  only  that  more  is  retained, 
than  in  health.  In  most  cases  we  can  show  clearly  enough  that 
the  quantity  produced  is  not  augmented.  Chill  an  inflamed  part 
and  a  healthy  part  to  the  same  point  at  the  same  time,  and  we 
find  that  the  healthy  part  the  soonest  arrives  at  the  normal  tem- 
perature. Leave  a  fevered  patient  with  his  burning  skin  exposed 
to  the  air,  and  he  will  grow  colder  than  a  healthy  person  under 


632  REVIEW. 

the  like  circumstances.  Again,  a  great  deal  of  the  heat  of  fever 
is  due  to  deficient  evaporation  by  the  skin  and  lungs,  and  under 
that  aspect  would  present  itself  as  the  direct  result  of  deficient 
function. 

Sixth  ohjcction. — When  people  talk  of  "  hyperpesthesia,"  and 
of  "sensibility  being  morbidly  increased,"  they  mean  that  more 
pain  than  ordinary  is  felt  in  certain  parts.  I  cannot  hear  that 
they  ever  find  agreeable  sensations  augmented.  No  patient  ever 
speaks  of  enjoying  his  morbid  feelings ;  his  capacities  in  this 
respect  are  not  raised.  Nor  have  I  ever  found  the  organs  of 
special  sense  made  really  more  perceptive  by  disease.  No  sounds 
inaudible  to  the  listening  ear  ever  fall  on  the  invalid's  auditory 
nerve,  nor  are  objects  beyond  the  range  of  vision  pictured  on 
his  retina.  It  is  true,  that  the  pains  they  feel  often  make  them 
attentive  to  slight  sounds  and  distant  sights,  which  the  by- 
standers have  passed  over ;  but  these  latter  never  fail  also  to 
hear  and  see  them  by  an  involuntary  direction  of  the  attention. 

Nor  are  the  common  sensory  nerves  rendered  more  accurate 
or  delicate.  I  have  tried  several  times,  by  the  test  of  its  appre- 
ciation of  the  distance  between  the  two  points  of  a  pair  of  com- 
passes, whether  a  spot  inflamed  with  gout  had  the  perceptive 
faculties  of  its  nerves  heightened  in  comparison  with  the  cor- 
responding part  of  the  opposite  side.  I  have  never  found  it  to 
be  so.  I  have  tried  the  same  experiment  on  parts  affected  with 
hysterical  so-called  "  hypersesthesia,"  namely  the  brow  and  the 
left  hypochondrium,  and  the  delicacy  of  touch  seemed,  if  any- 
wise altered,  to  be  lessened. 

To  call  this  hypersesthesia  an  increase  of  vitality  is  manifestly 
incorrect. 

Abnormal  sensibility  in  disease  has  two  forms  ;  first,  the  ex- 
altation of  it  in  parts  which  are  naturally  sensitive ;  and  second, 
its  establishment  in  parts  which  in  health  have  no  feeling.  Can 
either  be  viewed  as  an  augmentation  of  life  ?  Test  the  first  by 
the  gradual  production  of  indubitable  local  death  in  a  part. 
Burn  a  portion  of  skin  with  fire  or  a  caustic,  or  produce  a  slough 
by  pressure ; — the  entire  death  or  mortification  is  always  pre- 
ceded   by  pain.     And    this    pain    grows  worse  and   worse  the 


REVIEW.  633 

nearer  to  death  the  spot  approaches,  till  its  sudden  cessation  at 
the  period  of  the  virtual  disconnection  of  the  part  with  the  indi- 
vidual. It  seems  unreasonable  to  suppose  that  the  nearer  death 
a  part  is,  the  higher  should  be  its  life;  and  we  cannot  therefore 
accept  heightened  capacity  for  suffering  as  a  proof  of  height- 
ened life. 

Test  the  second,  namely  the  occurrence  of  morbid  sensibility 
during  the  inflammation  of  tissues  destitute  of  nerves  and  in- 
sensible under  ordinary  circumstances,  such  as  the  alimentary 
canal,  cartilages,  &c.  Where  is  the  pain  felt  ?  In  the  uninjured 
nervous  center.  And  where  is  the  nerve  that  communicates 
with  the  center  ?  Not  in  the  inflamed  painful  cartilage  but  at 
its  border.  By  the  disease,  by  the  lowering  of  life,  a  physical 
change  is  effected  in  the  cartilage  up  to  its  edge,  and  notice  of 
that  physical  change  is  transmitted  by  the  nerve.  The  nerve 
therefore  is  merely  engaged  in  an  ordinary  duty  of  giving  notice 
of  physical  change,  and  is  neither  more  or  less  active  than 
during  health. 

Since  the  publication  of  the  second  edition  I  have  read  ex- 
pressions of  dissent  from  a  principle  which  I  think  an  important^ 
one,  and  which  runs  through  the  whole  of  my  pathological 
reasoning,  namely  that  all  departures  from  the  normal  state 
such  as  render  a  man  less  capable  of  his  ordinary  duties  are  dis- 
eases. It  is  argued,  for  example,  in  some  lectures  published  by 
the  Professor  of  Physiology  at  King's  College,  that  I  have  no 
right  to  class  as  diseases  a  diarrhoea  or  a  diuresis  which  may  be 
produced  by  a  medicine  in  the  end  beneficial. 

A  grave  principle  is  here  involved. 

It  seems  to  me  of  the  utmost  importance  for  us  to  recognize 
that  every  phenomenon  which  is  not  health  is  disease,  and  essen- 
tial to  the  proper  understanding  of  a  morbid  state  to  see  that 
the  external  motive  cause  makes  no  difference  in  its  true  nature. 
The  state  in  question  is  the  same  whether  induced  by  a  physi- 
cian's medicine,  or  by  a  felon's  poison,  or  an  epidemic  malaria, 
climatic  influences,  or  organic  changes  in  a  patient's  body.  It 
would  obstruct  all  true  progress  in  physiology  if  we  called  it  when 


634  REVIEW. 

intentionally  produced  by  one  name,  and  when  unintentionally 
arising  by  another.  It  would  be  in  fact  to  assert  that  the  moral 
intention  of  the  doer  made  a  difference  in  the  physical  effect  of 
the  act.  A  statement  thus  baldly  of  the  reasoning  is  enough  to 
refute  it. 

An  objection  has  been  raised  by  the  same  Professor  against 
my  counsel  to  medical  men  to  turn  their  thoughts  towards  add- 
ing to  rather  than  towards  diminishing  the  materials  of  growth 
in  disease.  The  instance  of  pneumonia  is  quoted  as  in  point, 
where  it  is  said  our  aim  should  be  to  diminish  the  lymph  in  the 
lungs.  Now  I  suppose  nothing  is  so  calculated  to  diminish  the 
materials  of  lymph  as  mercury  and  frequent  venesection;  yet 
mercury  and  frequent  venesection  are  amply  proved  bv  experi- 
ence not  to  be  the  most  successful  means  of  treating  pneumonia. 
I  am  sure  that  the  mode  of  managing  the  patient  by  supplying 
the  materials  of  which  lymph  is  made,  as  set  forth  in  my  lectures 
on  pneumonia,  and  probably  practised  by  the  objector  himself, 
is  much  more  efficacious. 

As  a  matter  of  fact  have  any  of  the  efforts  made  to  destroy 
cancer,  tubercle,  or  any  other  morbid  material,  by  absorption 
or  by  depriving  the  system  of  the  materials  of  which  they  con- 
sist, ever  resulted  in  benefit  to  the  patient?  Is  not  the  real 
cure  effected  in  curable  cases  by  supplying  oil,  which  is  their 
main  basis  of  growth  ? 

The  instances  I  have  cited  are  of  well-approved  practice,  and 
in  concluding  I  would  say  that  I  trust  nobody  will  understand 
me  to  claim  any  exclusive  property  of  invention  in  the  plans  of 
treatment  which  I  advocate.  They  are  those  now  adopted  by 
all  the  most  earnest  and  liberal-minded  hospital  physicians. 
As  Dr.  Hayes  truly  says  in  the  article  reviewing  these  lectures 
in  the  "American  Journal  of  Medical  Science,"  I  "embody  into 
a  system  the  common-sense  of  clinical  experience."  I  take  the 
best  examples  of  successful  treatment,  and  I  endeavor  to  show 
that  at  the  foundation  of  them  all  lies  the  common  principle 
which  I  have  named  the  renewal  of  life.  Perhaps  this  is  a  less 
ambitious  task  than  the  building  up  of  theories  anticipatory 
of  experiment,  but  I  am  sure  it  is  more  likely  to  lead  to  useful 
results. 


REVIEW,  635 

To  the  objections  raised  by  my  reviewers  on  the  score  of 
words  and  expression  I  have  allowed  much  weight;  for  this  is 
in  a  great  measure  a  matter  of  taste,  and  I  wish  to  make  my 
volume  as  acceptable  as  I  can  to  the  profession.  The  language 
has,  in  deference  to  several  critics,  in  many  places  been  made 
less  homely,  where  that  could  be  done  without  departing  from 
the  colloquial  form  characteristic  of  clinical  lectures.  Again, 
at  no  little  trouble  to  myself  I  have  in  this  fourth  edition  had  a 
care  for  the  feelings  of  a  gentleman  who  appends  his  much 
respected  name  to  a  letter  in-  a  periodical,  complaining  of  my 
frequent  use  of  the  word  "drug,"  which  he  says  applies  only  to 
the  wholesale  article.  I  had  no  idea  how  often  I  had  offended 
till  I  came  to  amend.  Should  any  instance  have  escaped  my  pen, 
I  hope  it  may  be  considered  an  erratum.  The  use  of  italics 
and  capitals  for  the  purpose  of  emphasis  has  also  been  abandoned, 
and  I  believe  the  reviewer  was  right  in  thinking  the  aspect  of 
the  book  would  be  thereby  improved.  The  sacrifice  of  the 
original  title,  which  has  been  alluded  to  in  the  preface,  is 
another  instance  of  a  change  made  at  the  suggestion  of  a 
periodical. 


L '  E  N  V  0 1. 

Now  that  the  time  has  come  for  me  to  say  farewell,  I  would 
take  the  opportunity  of  pressing  upon  students  the  importance 
of  making  physiology  the  key-stone  and  binding  link  of  all 
their  knowledge,  and  the  firm  foundation  which  they  are  to 
crown  with  their  future  practice.  It  is  an  error,  deadly  to  the 
usefulness  of  our  profession,  to  say  or  do  anything  towards 
fostering  an  idea  that  the  organic  laws  of  health  and  disease  are 
different ;  it  is  still  worse  to  paint  them  as  in  opposition.  On 
the  modern  principles  of  dividing  labor  we  have  separate  lec- 
tures on  anatomy,  physiology,  pathology,  and  the  practice  of 
medicine ;  but  both  instructors  and  pupils  should  never  lose 
sight  of  these  as  branches  of  one  study,  as  being  in  truth  all 
limbs  of  the  same  tree  ;  and  those  who  follow  them  one  after 
the  other  should  still  pursue  the  same  end — a  knowledge  of 
man's  nature  with  a  view  to  the  culture  of  his  physical  well- 
being.  Each  special  professor  has  no  more  right  to  claim  the 
sole  teaching  of  students  to  be  medical  men,  than  the  shepherd, 
the  weaver,  or  the  tailor  can  arrogate  to  himself  the  credit  of 
adorning  our  backs. 

I  have  studiously  taught  that  no  new  modes  of  nature's  act- 
ing are  brought  into  play  by  disease  ;  its  chemistry  is  the  organic 
chemistry  of  health ;  the  same  mechanical  laws  are  exhibited ; 
the  relations  of  the  material  and  spiritual  world  therein  are  the 
same.  The  difference  consists  in  the  deficiency,  that  is,  the 
temporary  or  permanent  subtraction,  of  substance  or  power,  and 
not  in  its  unwonted  increase. 

I  will  frankly  grant  that  this  teaching  is  at  issue  with  certain 
notions  about  disease  handed  down  from  ancient  times,  and  in- 
fluencing the  practice  even  of  our  immediate  predecessors.  The 
prevailing  theory  would  represent  diseases  as  a  positive  material 


L'ENVOI.  637 

or  agency  alien  to  the  body,  to  cast  out  which  must  be  our 
principal  aim  in  our  endeavors  to  restore  health. 

This  idea  exhibits  itself  under  several  forms  which  I  will  ex- 
amine together.  Some  look  upon  the  morbid  phenomena  as 
"an  effort  of  Nature  to  destroy  some  noxious  matter,  and  to 
recover  the  patient  by  expelling  it  from  his  body."*  They 
would  make  the  chief  business  of  the  physician  consist  in  watch- 
ing the  proper  moment  for  aiding  this  elimination,  in  setting  it 
going,  or  in  substituting  instead  of  it  an  artificial  outlet  for  the 
"morbific  material." 

More  modern  branches  of  the  same  theory  are  the  chemical  and 
antidotal  systems  of  treatment,  which  have  both  nearly  the  same 
pathology  ;  they  look  upon  disease  as  an  active  foreign  substance 
which  only  requires  to  be  removed  or  rendered  inert  for  the  pa- 
tient to  be  restored  to  health.  A  materies  morhi  is  presupposed 
in  all  three  instances. 

That  a  few  diseases  are  the  result  of  the  introduction  into  the 
body,  or  of  the  formation  in  the  body,  of  a  noxious  agent  may 
be  frankly  conceded  ;  and  if  we  could  keep  this  agent  out  we 
should  keep  the  patient  well.  But  even  in  those  special  cases 
we  cannot  but  see  that  the  morbid  phenomena  continue  to  be 
displayed  after  the  expulsion  of  the  Qxcitant :  the  wound  re- 
mains after  the  sword  is  withdrawn,  the  burn  is  as  painful  when 
the  fire  is  out,  the  chill  is  felt  after  our  return  to  warmth  and 
comfort,  the  stomach  is  inflamed  though  the  irritant  poison  may 
be  neutralized. 

The  disease  we  have  to  cure  is  not  then  the  materies,  but  its 
consequences. 

Besides  which,  this  noxious  matter  is  in  most  instances  not 
foreign  to  the  body  at  all,  but  a  necessary  part  of  it,  only  re- 
quiring the  addition  of  a  fresh  constituent,  or  of  a  renewed 
function,  to  render  it  again  efficient.  Such  is  acid  in  the  sto- 
mach and  colon,  super-alkaline  blood,  anasarcous  serum  in  the 
tissues. 

To  another  physician  the  morbid  phenomena  present  a  differ- 

*  Sydenham,  ("  Obs.  Med.,"  cap.  i,)  defines  disease  to  "  Natunu  conamen,  ma- 
terise  morbifiae  exterminationem  in  iegri  salutem  omni  ope  molientis." 
41 


638  L'ENVOL 

ent  aspect.  He  regards  them  solely  as  exhibiting  a  phase  of 
nature,  but  a  phase  of  nature  different  from,  and  opposed  to, 
normal  anatomy  and  physiology.  Disease  is  to  him  an  active 
and  intelligent  living  foe,  at  war  against  his  friend  the  human 
body,  with  a  military  system  of  its  own,  to  be  studied  and  out- 
manoeuvred. There  is  a  contest  betM-een  Ormuzd  and  Ahriman; 
the  agencies  under  the  command  of  the  normal  life  are  arrayed 
against  the  pathological  life.*  On  these  grounds,  it  would  seem 
the  main  duty  of  the  medical  man  to  "weaken  life,"t  for  it  can- 
not be  denied  that  these  pathological  phenomena  are  in  a  gi'eat 
measure  of  a  vital  nature.  What  this  practitioner  fails  to  recog- 
nize, is  that  their  vitality  is  the  deformed  remains  of  the  normal 
vitality,  that  they  are  an  evidence  of  deficiency,  not  something 
in  excess,  in  fact  that  disease  is  "something  less  than  life." 

I  am  sure  that  physiology  as  it  is  now  taught  in  our  schools 
is  enough  to  clear  away  the  remaining  mists  of  these  partial 
truths.  They  cannot  stand  before  the  light.  To  us  now  health 
is  that  nicely  adjusted  balance  of  vital  functions  which  is  con- 
venient for  the  uses  men  put  their  bodies  to,  or  ease;  that  dis- 
ordered balance  which  is  inconvenient  is  bad  health  or  dis-ease. 
There  are  no  alien  forces  to  be  studied,  but  simply  varied  rela- 
tions arising  from  deficiency  of  one  or  other  of  the  ordinary 
functions  of  life,  and  a  consequent  want  of  balance  between 
them. 

Is  it  not,  then,  obvious  that  the  only  sure  mode  of  arriving  at 
a  knowledge  of  the  deficiencies  of  vital  powers,  or  diseases,  is 
by  a  knowledge  of  those  powers  of  which  they  are  deficiencies? 
The  physiologist  is  the  only  true  pathologist. 

And  as  to  the  use  of  medicines,  with  which  it  is  a  student's 
duty  to  be  acquainted,  do  you  not  see  that  the  safest  guide  to  a 
knowledge  of  their  effect  upon  a  disordered  body  is  the  knowl- 
edge of  their  effect  upon  a  healthy  body,  and  that  the  most  cer- 
tain way  of  advancing  the  art  of  healing  is  to  search  out  the 
essential  actions  of  physical  agents? 

*  "Krankbeit  ist  der  Kampf  desegoistiscben  Princips  (des  besondern  Lebens) 
mit  dem  planetariscben,  der  schiidlichen  Potenz,  die  es  zu  zersturen  suclit.'  — 
Scbunlein's  "Allg.  Patbologie,"  s.  1. 

f  See  note  to  page  81  iu  this  volume. 


L'ENVOI.  G89 

To  the  practitioner  I  will  urge  the  need  of  gaining  firm  faith 
in  the  work  he  is  engaged  in,  and  using  only  the  tools  he  can 
trust.  Without  this  he  can  look  back  with  no  conscientious  joy- 
on  his  daily  toil,  his  moral  nature  will  become  baser  and  baser 
day  by  day,  he  will  have  but  the  slighting  scorn  of  those  whose 
praise  he  should  value  in  old  age,  and  worse  than  all,  he  will 
deserve  it.  The  sooner  a  skeptic  leaves  our  profession  the  better 
for  his  peace  of  mind. 

By  a  skeptic  I  do  not  mean  one  who  disbelieves  that  which 
reason  shows  to  be  at  variance  with  that  which  he  himself  has 
ascertained  to  be  true.  Christian  converts  are  not  skeptics  when 
they  cast  out  the  idols  which  their  better  faith  tells  them  are 
false  gods;  nor  was  Galileo  a  skeptic  when  he  rejected  the  Ptole- 
maic astronomy  as  inconsistent  with  his  own.  The  character  I 
denounce  is  one  who  begins  by  pulling  down,  who  scornfully 
calls  useless  the  means  which  yet  he  traditionally  employs,  before 
he  has  got  better  to  take  their  place.  Such  a  turn  of  mind  never 
has  led  to  truth. 

The  right-thinking  practitioner  will,  as  Sydenham  did,  gain 
with  advancing  experience  more  faith,  he  will,  year  by  year, 
have  more  and  more  confidence  in  physiological  and  restorative 
treatment,  will  be  less  driven  to  fly  timidly  to  destructive  expe- 
dients. Like  that  great  and  honest-minded  man  he  will  cease 
to  resort  to  "z^ewa?  seetio  "  after  he  has  found  the  effect  of  '''■serum 
lactis"  suSicient.* 

To  non-professional  personsf  I  would  say,  examine  for  your- 
selves and  see  that  the  art  of  healing  is  a  true  work,  not  a  set 
of  rules,  not  a  doctrine,  but  a  real  means  of  adding  to  life  and 
happiness.  See — for  you  can  see  if  you  like — that  her  founda- 
tions are  not  opinion  or  traditional  notions,  but  a  sure  knowledge 
of  God's  woi'ks.  Not  mere  cleverness,  or  knack,  or  habit  learned 
from  others  can  be  the  chief  virtues  of  the  professor  of  this  art. 

*  See  note  to  page  164. 

f  These  sentences  are  takea  from  an  address  given  to  the  annual  meeting  at 
St.  Mary's  in  October,  1856;  to  which,  according  to  custom,  parents  and  other 
Qon-professional  friends  of  students  were  invited.  But  I  shall  not  be  sorry  if  in 
this  volume  also  I  may  be  addressing  some  laymen,  and  have  an  opportunity  of 
magnifying  my  office  to  them  as  well  as  to  our  own  brethren. 


640  L'ENVOI. 

There  is  scope  in  it  for  the  highest  and  broadest  intellects,  for 
wisdom,  prudence,  and  judgment,  as  well  as  for  the  moralities 
of  perseverance  and  charity.  He  in  our  profession  who  is  first 
in  the  scale  of  humanity  is  the  first  and  best  physician. 

I  would  call  upon  all  to  remember  what  a  high  matter  it  is  that 
we  take  upon  ourselves  to  handle.  Man's  life  ! — that  which 
makes  him  God's  viceroy  on  earth  ;  for  divorced  dust  and  spirit 
cease  to  hold  that  lofty  post.  To  aid  us  in  our  duty  we  are 
dowered  with  dominion  over  not  only  brute  matter  which  we  can 
number  and  weigh,  but  over  those  unseen  forces  which  our  rea- 
son makes  known  to  us  ;  heat,  electricity,  vitality,  and  maybe 
other  yet  nameless  "Powers  of  the  Lord."  Our  business  is  to 
use  them  to  lengthen  and  lighten  man's  earthly  trial.  Every 
minute  that  our  ministrant  zeal  upholds  it  in  vigor  fosters  a  fresh 
hope  of  working  out  salvation  for  himself  and  others ;  every 
minute  by  which  it  is  shortened  damps  that  hope. 


INDEX. 


Absorption,  deficiency  of,  in  disease, 
496,  546 

—  rapidity  of,  in  serous  membranes, 
211,  474 

Acid  diarrhcea,  556 

—  formed  in  body,  44,  495,  513.  518 
Acids,  mineral,  as   a  remed}',  45,  100, 

109,  336,  348,  522 
Acupuncture,  460 

Acute  rlicumatism,  see  Rheumatic  fever 
Affusion,  97 

African  disposition,  314 
Age     as    affecting-    administration    of 

alcohol,  133,  248 

—  as  affecting  bloodletting,  252 

—  as  affecting  occurrence  of  emphy- 
sema, 286 

—  as  affecting  prognosis  of  corpulence, 
586 

—  influence  of,  on  the  mind,  431 
Ague,  461 

Air  in  stomach,  535 
Albuminuria,  452 — 469 

—  pleurisy  in,  194 

Alcohol  absorbed  without  change,  578 

—  as  a  cause  of  disease,  472,  581,  602 

—  as  a  remedy,  46,  102,  109,  122,  131, 
133,  248,  261,  271,  283,  295,  298, 
533,  543,  604,  608 

—  experiments  on,  599 

—  formed  in  stomach,  535 

—  in  albuminuria,  257,  457 

—  in  heart  disease,  337 

Alkalies  as  remedies,  45,  145,  150,  153, 

164,  566 
Aloes,  use  of,  362,  559 
Alternations  of  heat  and  cold,  148,  160, 

186, 187 
Amenorrhoea,  41,  357 
Ammonia,  formation  of,  in  body,  99 

—  remedial  use  of,  46 

Anoemia,  25,  314,   316,   327,  333,  336, 

337,  353,  367,  372,  464,  562,  613 
Anaesthetics,  52,  607 
Anasarca,  36,  457.  553 
Aneurism,  309,  323 
Angina  pectoris.  338 
Antimony,  110,  227,  249,  260,  272,  285 


Apoplexy,  bloodletting  in,  618 
Arrest  of  animal  heat,  97 

—  metamorphosis,  43,  5!,  98,  546,  564 
Arsenic  as  a  remedy,  391,  394 
Artificial  hysteria,  416 

Ascites,  470,  479,  504 
Asphyxia,  41 
Astringents,  47,  528,  556 

—  in  albuminuria,  454 
Atrophy  of  muscle,  19,  375,  387 
Auscultation,   hints   on,   145,   148,  160, 

183,    263,  275,    282,    289,    329,    334, 
341 

Bedding,  145,  146,  166 

Bed-sores,  115,  130,  187,  460 

Beer,  611 

Bile,  44,  547,  560 

Bilious  attacks,  524 

—  diarrhoea,  547 
Biliousness,  561, 

Blisters,  use  of,  82,  184,  196,  200,  212, 

285,  386,449,  530 
Blood-diseases,  347,  355 
Blood,  htematine  in,  613 
Blood  in  fteces,  550 

—  in  urine,  453 

Bloodletting,  49,  82,  103,  153,  157,  164 

note,    196,    239,    243,   315,   321,  336, 

613—626 
Bloody  sweat,  436 
Brain,    clots   in,  without   apoplexy   or 

paralysis,  351 
Bromide    of  potassium   as   a   remedy, 

404 
Broom,  see  Scoparium 
Brow-ague,  515 

Cachexia  in  consumption,  302 

Caecum,  collection  of  faeces  in,  569 

Cancer,  22,  39,  3G9,  629 

Carbonic  acid,  its  use  in  the  body,  45,  80 

Carditis,  153,  see  also  Pericarditis 

Catamenia  misplaced,  436 

Catarrh,  capillary,  230—237 

—  of  the  stomach,  524 
Champagne,  544,  5S4,  611 
Charcoal  as  a  remedy,  540,  559 


G42 


INDEX. 


Chlorate  of  potash  as  a  remedy,  303, 

460 
Chloride  of  sodium  as  a  remedy,  337 
Chlorides  in  urine,  94,  C02 
Chlorine  as  a  disinfectant,  101,  143 

—  as  a  remedy,  360 

Chloroform  as  a  local  remedy,  449,  543 
Chorea.  388—407 

—  and  rheumatism,  191 

Chossat's  observations  on  inanition,  33 
Cinchona    as   a  remed}',  47,    131,   133, 

485 
Circulation,  ceficiency  of,  in  paralysis, 

606,  nole 
Classification,  31,  33 
Climate,  bad  influence  on  health,  415, 

431 

—  change  of,  as  a  remedy,  300,  323, 
335,  415,  426,  503,  557 

Clinical  study,  hints  on,  13,  51,  note, 
52,   251,  266,  308,  340,  412,  450,  510 

Cold  as  a  remedy,  148,  344,  522,  544, 
see  Shower-baths 

Colon,  flatus  in,  569 

Compensation,  51 

Constipation.  567 

Constructives,  28,  44 

Consumption,  288 — 308 

Contagion,  see  Infection 

Corpulence  contra-indicates  blood- 
letting, 315 

—  lecture  on,  579 — 587 
Costiveness,  560 

Cough,  hysterical,  426,  433 
Cramp  in  the  stomach,  533 
Creasote,  543 

Cumulation   of  medicine   in  body  ex- 
plained. 349,  470 
Cure,  30,  42 
Curiosity,  429 

Death,   partial,   22,   96,   137,  452,  455, 

484,  487,   625 
Death,  total,  13,  30,  487,  632 
Decay  of  dead  bodies — Death,  15 

—  live  bodies — Life,  15 
Degeneration,  20,  38,  276 
Delirium  in  rheumatic  fever,  160,  189 
Delirium  tremens  and  pneumonia,  203, 

268 

—  purgatives  in,  506 

Devergie's  observations  on  decay,  15 

Diabetes,  480—486 

Diagnosis,  errors  in,  101,  note,  119,  136, 

150,  168,  255,  261,  317,  467 
Diarrhoea,  546—559,  561 

—  in  consumption,  301 

—  fever,  95,  109,  115,  120,  242 

—  pneumonia,  249,  271 
Dietetics,  570—578 


Digestion,  action  of  mind  on,  360,  515 

—  action  of,  on  mind,  4!i4 

—  compared  with  decomposition,  519 

—  deficiency  of,  as  a   cause   of  death, 
40 

—  importance  of,  in  therapeutics,  493 
—498 

Digestive  tract  single.  4;i8 
Digitalis  as  a  remedy,  214,   321,   322, 
326,  328,  337,  344,  348,  456 

—  contraction  of  heart  from,  345 
Dilataiion  of  stomach,  5  37,  note 
Dirty  remedies,  306,  589 

Disease,  what  it  is,  19,  2<3,  289,  511,  637 

Dropped  hand,  383 

Dropsy,  see  Ascites,  Anasarca,  Uydro- 

thorax 
Dumbness,  nervous,  417 
Duration  of  Bright"s  disease,  464 

—  cardiac  disease,  329 

—  chorea,  389 

—  rheumatic  fever,  151,  164 

—  typh-fever,  131 
Dysenteric  diarrhoea.  242,  549 
DyspncEa  as  a  guide   to   bloodletting, 

245 
Dyspepsia  from  cardiac  disease,  341 

Eczema,  303,  624 

Effete  matter,  retention  of.  563 

Eflbrts  of  nature,    157.  202,  272,  284, 

316,637 
Effusion,  morbid,  35,  203,  209 
Eggs,  99,   578 
Elaterium,  459,  504 
Electricity  as  a  stimulant,  46 
Emaciation,  34,  36,  113,  128 
Emetics  in  fever,  90,  97,  109,  132 
Emmenagosrues,  41 
Emphysema  of  lung,  237,  274—287 
Empyema,  204,  219 
Endemic  disease,  55'i 
Enemata,  nutrition  by.  226.  228,  426 
Epilepsy,  402—407 
Epistaxis  as  a  remedy,  157 

—  fatal,  466 
Epithelium,  57,  137 
Eructation,  534 — 545 
Erysipelas,  contagion  of.  141 

—  purgatives  in,  506 
Excess  of  life,  19,  519,  628 
Exercise,  muscular,  20,  48,  339,  379 

—  as  a  remedy,  392,  416 
Experiments    on   medicines,   308,   450, 

459,  484,   598,  605 

Expiration    efficient    cause  of  emphy- 
sema, 277 

Eye,  appearance  of,  in  hysteria,  412 

Fieculeut  vomiting,  542 


INDEX. 


643 


Febricula,  89 

Fetor  of  evacuations,  37,  115,  509 

Flatulence,    342,    421,    476,  517,    558, 

569,  591 
Fleabites,  128 

Flesh  converted  into  sugar,  483 
Fonaentations,     145,      149      (see     also 

Warmth,  as  a  remedy') 
Food,  digestibility  of,'572,  577 

—  liquid  and  solid,  108,   133,  227,  486, 
490,  571,  576,  581 

Gallic  acid  as  a  remedy,  344,  529 

Gastralgia,  514,  524,  596 

Giant,  382 

Globus  hystericus,  410,  537 

Glottitis,"222,  623 

Gonorrheal  rheumatism,  164,  180 

Gout,  446,  497 

Green  stools,  547 

Hsemoptysis  after  muscular  efforts,  256 

—  hysterical,  433 
Hemorrhage,  cerebral,  351 

—  from  ruptured  capillaries,  343 

—  from  the  stomach,  542 

—  in  skin  (see  Purpura) 

—  symptoms  accompanying,  631 
Hemorrhoidal  sciatica,  449 
Hair  cut,  139 

Health  and  disease,  30,  633,  636 
Heart  a  single  organ,  334 

—  as  a  cause  of  pneumonia,  262 

—  as  a  guide  to  bloodletting,  244 

—  bloodletting  in  diseases  of,  624 

—  chronic  diseases  of,  324 — 342 
Heart,  dilated,  contra-indicates  liquid 

diet,  571 

—  dislocation  of,  216,  219 

—  duration  of  diseases  of,  329 

—  inflammation  of,  (see  Carditis,  Pe- 
ricarditis) 

—  organic  disease  of,  a  cause  of 
anremia,  366 

—  protection  of,  in  rheumatic  fever, 
147 

Heartburn,  513 

Hereditary  naiure  of  corpulence,  580, 
581,  586 

Hydrochloric  acid  as  a  remedy,  100, 108, 
337,  4)8 

Hydrocyanic  acid  as  a  remedy,  342, 
'516,  543 

Hydrothorax,  idiopathic,  203—220 

Hyperajsthesia,  411,  632 

Hypertrophy  different  from  mere  en- 
largement, 386,  628 

—  how  induced,  381 
Hyposulphite  of  soda,  530,  540 
Hysteria,  408 — 437 


Ice  for  vomiting,  544 

Ichor,  76 

Impetigo,  303 

Impotence,  380 

Inanition  as  a  cause  of  disease,  33, 116, 

226,  229,  336,  351,  447,  507 
Indigestion,  499,  523 
Infection,  112,  114,   121,  124,  140,  142, 

428 

—  prevention  of,  143 
Inflammation,  23,  73,  77,  80,  196 

—  spread    of,    without  vascular   con- 
nection, 197 

Inhalation,  233 

Inspiration,  mechanism  of,  277 

Iodine   and    Iodides   as    remedies,   48, 

146,  152,  159,  160,  161, 169,  178,  386, 

405,  439,  485,  585 
Ipecacuanha,  110 
Iron  as  a  remedy,  44,    280,   282,   295, 

322,    327,  336,   360,    456,  473,   505, 

529,  556 
Italian  climate  bad  for  hysteria,  415 

—  fever,  109,  116 
Italy,  diarrhoea  in,  558 

—  rarity  of  aneurism  in,  322 

Jaundice  treated  by  smelling  elaterium, 
459  note 

Kidneys,  congestion  of,  478,  623 

—  degenerated  in  pneumonia,  257 
Kidneys,  forms  of  degeneration  of,  454, 

463, 468 
Kino  as  a  remedy,  528,  556 

Laryngitis,  acute,  221 — 229 

—  chronic,  228 

Laurel  leaves  as  a  remedy,  146,  568 

Li-ad  poison,  384 

Leeches,    49,  146,    183,   244,  315,   319, 

436,  544,  622 
Lemon-juice,  163,  558 
Life  and  death   compared,  14,  15,  359, 

630 

—  cannot  be  in  excess,  19 

Liquid    diet   injurious    io    corpulence, 
581 

—  injurious  in  disease  of  heart,  572 
Lobelia,  284 

Low  fever  (see  Typh-fever) 
Lunacy,  414,  430,  631 

Malaria,  380,  415,   431,   448,  515,  562, 

609 
Malformations,  312 
Marriage  as  a  cause  of  disease,  338 

—  as  a  remedy,  559 
Masturbation  a  cause  of  chorea,  399 
Materies  morbi,  96,  637 


641 


INDEX. 


Meals,  98,  361,  425,  507,  533,  5Tl 
Measles,  contagion  of,  141 
Melancbolv,  5G2 
Melanosis,"  34,  101,  197 
Meningitis  of  spinal  cord,  440 
Menorrhagia  relieved  by  digitalis,  321 
Mercury,  50,   185,  200,  213,   224  note, 

227,  242,  249,  ■^eo,  272,  284,  295,  45G, 

531,  554 
Metamorphosis,    effect    of   alcohol    on, 

601 
Metastasis  of  gonorrhoea,  171 

—  of  rheumatic  fever,  147 
Miliaria,  110 

Milk,  98,  533,  544,  555,  576,  578 
Mind,  action  of,  on  digestion,  359,  515, 
531 

—  influence  of,  in  hysteria,  413 

—  remedial  action  of,  on  digestion, 
359 

in  antemia,  364 

in  chorea,  391 

in  epilepsy,  407 

Mortification,  4a7 — 492  (see  also  Bed- 
sores) 

Mucopurulent  diarrhcsa,  549 

Mucus  membranes,  pathology  of,  23,  36, 
73,  80,  359 

physiology  of,  54,  358 

Mucus  and  pus,  formation  of,  54 — 85 

—  insolubility  of,  impediment  to  diges- 
tion, 50,  52"'7,  591 

—  vomited,  541 

Nitrate   of  silver,  internal   use   of,  47, 

529 
Niter  as  a  remedy,  164,  214 
Nosology,  26,  31,  409,  412 
Nursing,  importance  of,  152 
Nutrition   as  a  remedy,  108,  226,  265, 

271,  294,322,360,  367,  381,  422,  437, 

476,  481,  488,  497,  507,  553,  566,  573, 

592. 

—  by  eneraata,  226,  228,  426,  544 

—  want  of  (see  Inanition,  Starvation) 

Obesity  (see  Corpulence) 
Objections  answered,  627 — 640 
Occupation,  action  of,  on  mind,  364 
Oil  as  a  remedy,  83,  283,  296,  496,  568, 

574 
Oil,  cod-liver,  sorts  of,  297 
Oily  diet,  298,  582 
Opium,   146,   153,    188,    189,   259,   260, 

284,  449,  484,  544,  556,  559 
Over-cooiiing,  578 
Over-training,  379,  585 
Oysters,  222,  227,  578 
Oxygen,  action  of,   on  inflamed  parts, 

78,  137,  233,  460,  490 


Pain,  remarks  on,  24,  93,  154,  182, 190, 

446,  515,  517,  633 
Paracentesis,  218 
Paralj'sis,  hysterical,  417,  423,  434 

—  local,  445 

—  natural  end  of,  600 

—  of  the  lungs,  234 

—  organic,  380,  386 

—  spinal,  438—441 

—  vesical,  446 

Pepsine,  44,  376,  528,  556,  575,  588,  597 

Perfumes,  418 

Pericardial  and  endocardial  murmurs, 

183 
Pericarditis,  bloodletting  in,  623 

—  common  in  children,  400 

—  fatal  cases  of,  166,  192 

—  non-rheumatic,  188 

—  rheumatic,  153,  157,  166,  181 
Peritonitis,  428 

—  bloodletting  in,  623 
Phosphates  in  urine,  42,  94,  600 
Piles,  363,  561 

Pleurisy,  192—202 
Pleurisy,  bloodletting  in,  586 
Pleuropneumonia     and    bronchopneu- 
monia, 236,  258,  265,  266,  268 
Pneumonia,  238—273 

—  and  delirium  tremens,  263,  268 

—  bloodletting  in,  620 

—  in  albuminuria,  463 

—  in  measles,  258 

—  in  typh-fever,  97,  121 

—  morientum,  270 

—  opium  in,  259 

—  State  of  lung  during  cure  of,  262 
Pneumonias,  two  in  same  patient,  255 
Porter,  bottled,  544 

Port  wine,  611 

Posture  as  affecting  diarrhoea,  558 

—  as  affecting  vomiting,  424,  541,  544 
Potash,    bicarbonate  of,  as   a  remedy, 

152,  164 
Potassa;  liquor  in  obesit}',  585 
Poisons,   morbid,  genesis  of,   89.    114, 

121,  124,  161 
Poultice,  bark,  130 

—  linseed,  125,  127,  146,  154,  169,  183, 
197,  213,  246,  554 

—  jacket,  how  to  make,  247 

—  of  laurel  leaves,  146,  568 

—  yeast,  79,  490 

Pregnancy  as  a  cause  of  chorea,  398 

—  as  affecting  treatment,  170,  261,  390, 
398 

Practice,  revolutions  in,  27,  164,  616, 

636 
Prodromus  of  fevers,  89 
Prognosis  in  albuminuria,  453 
Prominence  of  eyeballs,  368 — 374 


INDEX. 


04; 


Pulmonary  consumption,  288 — 308 
Pulse,  reduplicating,  260 
J'uncture  of  skin  in  dropsy,  460 
Purgatives,    general   use    of,    48,    506, 
523,  554,  564 

—  in  an;vmia,  362,  367 

—  in  dropsy,  460 

—  in  gastralgia,  531 

—  in  pneumonia,  249,  272 
Purpura,  162,  343— 352 
Pus,  growth  of,  69 

—  low  vitality  of,  39 
Pyemia,  170,  201 

Quackery,  306,  567 

Quinine,  observations  on,  516,  576 

Race  as  affecting  tolerance  of  blood- 
letting, 616,  note 
Relapses  in  fever,  111,  120,  132 
Renewal  of  blood,  614 

—  of  flesh,  17,  303,  401,  497 

Rest  in  disease,  118,  125,  147,  269,  304, 

326,  381,  488 
Rheumatic  fever,  144 — 167 

—  connection  of,  with  chorea,  399 

—  duration  of,  151,  164 

—  exceptional  cases  of,  158,  162 

—  miliaria  in,  116 

—  relapses  in,  154 

—  statistics  of,  164 
Rheumatism,  subacute,  144 

Rich  and  poor,  duration  of  disease  in, 

333,  336 
Rigors  in  typh-fever,  93 

Saliva,  action  of,  521,  574 

—  vomited,  542 
Sarcina  ventriculi,  538 
Scarlatina,  contagion  of,  141 
Scarlatinous  dropsy,  479 
Skepticism,  639 

Sciatica,  442 — 451 

Scoparium,  214,  471 

Sea-sickness,  544 

Sensation,  morbid  in  insensitive  parts, 

339,  513,  632 
Serous  membranes,  activity  of,  210 
Shower-baths,  417,  425,  432,  434 
Smallpox,  78,  122,  134 
Snake's  dung  as  a  remedy,  306 
Solubility  of  medicines,  361,  577 
Spinal  paralysis,  438 — 441 
Squill,  214,  285,  295,  457 
Stammering  a  form  of  chorea,  395 
.Starchy  food,  572 
Starvation  as  a  cause  of  disease  (see 

Inanition) 

—  as  a  remedy,  146,  155,  163,  314,  336, 
573,  583,  616,  625 

42 


Starvation  from  vomiting,  544 
Statistics  of  rheumatic  fever,  1  64 

—  typh-fever,  106 

—  valuation  of,  107 
Stimulus.  45,  148,  605 
Stomach,  atrophy  of,  594 

—  dilated,  537,  note 

—  importance  of,  104 

—  to  be  spared  work,  5T0 
Strychnia,  46,  296,  337,   456,  476,  523, 

534,  540,  559 
Sudamina,  116 
Succussion,  46 
Sugar  as  food,  45,  481,  517,  582 

—  formed  from  liver,  483 

—  formed  from  starch,  520 
Sulphate  of  copper,  47,  361,  556  ■ 
Sulphates  in  urine,  94,  601 
Sulphur  baths,  386 

Sulphuric  acid  as  a  remedy,  102,  344 
Swallowing  in  the  erect  posture,  424 
Symptoms  and  organic  changes,  509 
Syphilis,  50,  136,  153,  168 
Syphilitic  sciatica,  448 

Tadpoles,  Mr.  Higginbottom's,  1 98 

Tapping  abdomen,  473 

Tea,  421 

Temperament  as  affecting  disease,  287, 

467 
Theory  and  practice,  14.  634 
Thirst  in  diabetes,  486 
Tobacco,  284 
Tonics,  46,  105 
Tracheotomy,  222,  224 
Tubercle,  how  fatal,  290 

—  chalky,  291 

Turpentine  as  a  remedy,  344,  444.  448, 

555 
Typh-fever,  86—133 

—  acid  in  (see  Acids,  mineral) 

—  bloodletting  in,  621 

—  comparison  of,  with  smallpox,  123 

—  contagion  of,  114,  124,  141 

—  danger  of  exertion  in,  118.  125 

—  duration  of,  132 

—  emetics  in  (see  Emetics) 

—  fatality  of,  108,  117 

—  pneumonia  in,  103,  241,  24rt,  262 

—  ulcerated  bowels  in,  118 

—  wine  in  (see  Alcohol  as  a  remedi/) 
Typhus  and  Typhoid,  distinction  of,  sj  . 

112,  114,  115,  123,  125,  126 

Ultimum  moriens,  34,  62,  304 
Urajraia,  41 
Urethritis,  171 

Urine,  analysis  of,  under   influence  of 
alcohol,  599 

—  blood  in,  453 


646 


INDEX. 


rrine,     incontinence    of,    relieved   l)y 
digitalis,  ;i22 

—  in  typh-fever,  90,  'J'.i 
rterus,  absence  of,  311,  410 

—  action  of  mind  on,  414 

Vaccination,  140 
Vaginitis,  80,  l'J9,  171 
Valerian,  45,  418,  432,  54i) 
Valves  of  heart,  disease  of,  as  a  cause 
of  non-development,  373 

—  ruptured,  338 

— •  statistics  of  injuries  to,  32."i,  32ii 

Vapor  baths,  459 

Vinegar  for  corpulence,  58i! 

Vital  acts,  519 

Vomiting,  540—544 


Vomiting,  hysterical.  423,  595 

—  in  albuminuria,  462 

—  in  fever,  91 

Warm  baths,  caution  as  to  temperature 

of,  458 
Warmth  as  a  remedy,  45,  84,  147,  154, 

197,    213,    228,    233,    246,    271,   449, 

458,  544 

—  animal,  augmented,  95 

diminished  by  alcohol,  <)07 

Water  as  a  remedv,  44,  48,  522,  530, 

565 
Will,  action  of,  as  a  remedy,  389,  398, 
426,  437 

Zinc,  valerianate  of,  419,  540,  544 


The   Ekd. 


t% 


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